An evaluation of a care coaching and provider referral intervention for behavioral health needs.

OBJECTIVES: To evaluate changes in health care spending and utilization associated with a telehealth-based care coach-supported and behavioral health (BH) provider referral intervention in the United States. STUDY DESIGN: Observational retrospective cohort study with propensity score matching of treated and control groups. METHODS: Difference-in-differences (DID) analysis was used to calculate per-member per-month (PMPM) savings and changes in utilization in a treated group relative to matched controls over 36 months. The study included 1800 adults with substance use disorder (SUD), anxiety, or depression who were eligible for the intervention. Treated members (n = 900) graduated from the program. Matched control members (n = 900) were eligible but never enrolled. Primary outcomes included all-cause and disease-attributable health care cost and utilization PMPM, categorized by place of service. RESULTS: There were statistically significant reductions in total all-cause medical costs of $485 PMPM (P < .001) and a 66% pre-post reduction in inpatient encounters, with $488 PMPM DID savings for inpatient admissions (P < .001) among the treated cohort compared with the control cohort over 36 months. Conversely, there were statistically significant cost increases ($110 PMPM; P < .001) for all-cause office visits in the treated cohort compared with the control cohort. Similar results were seen in SUD-attributable and BH-attributable costs. CONCLUSIONS: Although the results could be affected by unmeasured confounding, they suggest that care coaching interventions that offer BH provider referrals may produce long-term savings, reductions in avoidable utilization, and increases in targeted services to treat BH conditions. Rigorous evaluations are needed to confirm these findings.

Intersecting systemic and personal barriers to accessing social services: qualitative interviews in northern California.

BACKGROUND: Addressing social risks in the clinical setting can increase patient confidence in the availability of community resources and may contribute to the development of a therapeutic alliance which has been correlated with treatment adherence and improved quality of life in mental health contexts. It is not well understood what barriers patients face when trying to connect to community resources that help address social risks. This paper aims to describe patient-reported barriers to accessing and using social needs-related resources to which they are referred by a program embedded in a safety net primary care clinic. METHODS: This is a qualitative assessment of patient-reported barriers to accessing and using social needs assistance programs. We conducted over 100 in-depth interviews with individuals in Northern California who participated in a navigation and referral program to help address their social needs and describe a unique framework for understanding how policies and systems intersect with an individual's personal life circumstances. RESULTS: Individuals described two distinct domains of barriers: 1) systems-level barriers that were linked to the inequitable distribution of and access to resources, and 2) personal-level barriers that focused on unique limitations experienced by each patient and impacted the way that they accessed services in their communities. While these barriers often overlapped or manifested in similar outcomes, this distinction was key because the systems barriers were not things that individuals could control or overcome through their own initiative or by increasing individual capacity. CONCLUSIONS: Respondents describe intersecting systemic and personal barriers that compound patients' challenges to getting their social needs met; this includes both a picture of the inequitable distribution of and access to social services and a profile of the limitations created by individual life histories. These results speak to the need for structural changes to improve adequacy, availability, and accessibility of social needs resources. These findings highlight the need for advocacy to address systems barriers, especially the stigma that is faced by people who struggle with a variety of health and social issues, and investment in incentives to strengthen relationships between health care settings and social service agencies.

Risk-Adjusted Cost Performance for 90-Day Total Hip Arthroplasty Episodes: Comparing US Hospitals Nationwide Before CJR.

BACKGROUND: We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance. METHODS: We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals. RESULTS: Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P < .001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P < .001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level. CONCLUSION: Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.

Risk-Adjusted Cost Performance for 90-Day Total Knee Arthroplasty Episodes: Data and Methods for Comparing U.S. Hospitals Nationwide.

BACKGROUND: We propose a model to characterize the variation in total knee arthroplasty (TKA) episode payments in the U.S. Medicare population to establish a baseline prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model. METHODS: We identified TKA episodes in Medicare Part A (100% sample) from 2014 to 2016 (n = 717,690) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed effects (age, sex, race, comorbidities) and region-level (U.S. Census Regions) and hospital-level random effects. Random-effect estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3,217) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high and low-performing hospitals. RESULTS: During this period, the mean Part A episode payments declined throughout the United States ($18,665 to $16,978; p < 0.001), primarily because of decreased post-acute care payments ($6,401 to $4,873; p < 0.0001). The 90-day readmission rates fell by nearly 20% (7.2% to 5.8%; p < 0.001). We found significant variation (p < 0.05) in risk-adjusted episode payments, post-acute care utilization, and readmission rates across regions and even hospitals. The share of hospitals in each geographic region that were low-performance outliers for episode payments ranged from 13% to 31% and those that were high-performance outliers ranged from 16% to 30%. CONCLUSIONS: Medicare Part A payments for TKA episodes were decreasing prior to the CJR model because of decreases in both post-acute care utilization and hospital readmissions. A significant variation in risk-adjusted hospital cost performance remained. Our results provide a baseline against which to measure the impact of alternative payment models and a methodology by which to measure hospital-level performance, which can be compared with peer hospitals and national benchmarks.

Patient Perspectives on Addressing Social Needs in Primary Care Using a Screening and Resource Referral Intervention.

BACKGROUND: Interest is growing in interventions to address social needs in clinical settings. However, little is known about patients' perceptions and experiences with these interventions. OBJECTIVE: To evaluate patients' experiences and patient-reported outcomes of a primary care-based intervention to help patients connect with community resources using trained volunteer advocates. DESIGN: Qualitative telephone interviews with patients who had worked with the volunteer advocates. Sample and recruitment targets were equally distributed between patients who had at least one reported success in meeting an identified need and those who had no reported needs met, based on the database used to document patient encounters. PARTICIPANTS: One hundred two patients. INTERVENTIONS: Patients at the study clinic were periodically screened for social needs. If needs were identified, they were referred to a trained volunteer advocate who further assessed their needs, provided them with resource referrals, and followed up with them on whether their need was met. APPROACH: Thematic analysis was used to code the data. KEY RESULTS: Interviewed patients appreciated the services offered, especially the follow-up. Patients' ability to access the resource to which they were referred was enhanced by assistance with filling out forms, calling community resources, and other types of navigation. Patients also reported that interacting with the advocates made them feel listened to and cared for, which they perceived as noteworthy in their lives. CONCLUSIONS: This patient-reported information provides key insights into a human-centered intervention in a clinical environment. Our findings highlight what works in clinical interventions addressing social needs and provide outcomes that are difficult to measure using existing quantitative metrics. Patients experienced the intervention as a therapeutic relationship/working alliance, a type of care that correlates with positive outcomes such as treatment adherence and quality of life. These insights will help design more patient-centered approaches to providing holistic patient care.

Mechanisms Associated with Clinical Improvement in Interventions That Address Health-Related Social Needs: A Mixed-Methods Analysis.

Linking individuals to community resources in order to help meet health-related social needs, such as food, medications, or transportation, may improve clinical outcomes. However, little is known about the mechanisms whereby such linkage interventions might improve health. The authors conducted a mixed-methods analysis consisting of outcomes from a prospective cohort study of a linkage intervention and a qualitative analysis of case records from participants. The cohort study included intervention participants who first enrolled between December 2014 and March 2015. Participants were excluded if they could not complete the assessment because of illness or language. The authors examined changes in cost-related medication underuse (CRMU), transportation barriers, and food insecurity (FI). For the qualitative analysis, a random sample of 80 participants was selected for electronic health record review - 40 cases who showed clinical improvement (responders) and 40 cases who did not (nonresponders). Themes were extracted by 3 reviewers guided by the immersion/crystallization approach. For the cohort study, 141 individuals were included; 138 (97.9%) completed follow-up. Comparing baseline to follow-up, there were significant reductions in the prevalence of CRMU (from 44.2% to 39.1%, P = .003) and transportation barriers (from 46.3% to 30.2%, P = .001), but not FI (from 40.4% to 38.2%, P = .73). For the qualitative study, emergent themes that helped differentiate responders and nonresponders included acuity of need, resource availability/access, and adequacy of the resource utilized. CRMU and transportation barriers may be important mechanisms by which linkage interventions improve health-related social needs. Patient-centered themes can help guide intervention improvements.

Clinical and Economic Burden of Commercially Insured Patients with Acromegaly in the United States: A Retrospective Analysis.

BACKGROUND: Acromegaly is a chronic disorder characterized by excess growth hormone secretion and elevated insulin-like growth factor-1 levels most often caused by a pituitary adenoma. Clinical presentation of the disease includes coarsening of the facial features, soft-tissue swelling of the hands and feet, and overgrowth of the frontal skull and protrusion of the jaw, as well as joint symptoms. Acromegaly is associated with several comorbidities, including diabetes, cardiovascular disease, and arthropathy, which, if left untreated, can lead to early mortality. Surgery to remove the adenoma is the first-line treatment for many patients, but more than 50% of patients will require additional pharmacologic or radiation therapy. OBJECTIVES: To (a) determine the clinical and economic burden of illness among patients with acromegaly using administrative claims data from a large, commercially insured population in the United States and (b) estimate the most frequent acromegaly-related comorbidities and health care resource utilization and costs among these patients. METHODS: This retrospective, observational cohort study used administrative claims data from the HealthCore Integrated Research Database, containing a geographically diverse spectrum of longitudinal claims data from the largest database of commercially insured patients in the United States. Patients were aged ≥ 20 years and fulfilled ≥ 1 of the following criteria during the intake period (March 31, 2008-July 31, 2012): ≥ 2 independent diagnostic codes for acromegaly, ≥ 1 acromegaly diagnosis code and ≥ 1 acromegaly-related procedure code, or ≥ 1 acromegaly diagnosis code and ≥ 1 medical claim for acromegaly-related therapy. The index date was defined as the date of the first medical claim for acromegaly within the intake period. Assessed outcomes included prevalence of acromegaly diagnosis and incidence of new acromegaly diagnoses during the study period (January 1, 2008-July 31, 2013), acromegaly-related comorbidities, and pharmacotherapy use. Because 2008 and 2012 data were incomplete, incidence rates were only reported for 2009, 2010, and 2011. Total and acromegaly-related health care resource utilization and annual health care costs were analyzed during a 12-month post-index observational period. RESULTS: In total, 757 patients with acromegaly met the selection criteria for this study, with a mean age of 49.3 years (53.6% female). The total prevalence of acromegaly was 41.7 cases per million. Acromegaly incidence was 15.0, 13.3, and 9.5 cases per million in 2009, 2010, and 2011, respectively. The top 5 acromegaly-related comorbidities were hypertension, diabetes, hypothyroidism, arthropathy/arthralgia/synovitis, and sleep apnea. During the study period, 51% of patients (n = 385) used acromegaly-related pharmacologic therapy, with the most common being cabergoline and octreotide (used by 12.4% and 12.2% of patients, respectively). Overall, 18.8% of patients incurred an acromegaly-related inpatient stay; 97.0% used outpatient services other than emergency room (ER) or physician visits; 74.8% had a physician office visit; and 1.8% visited the ER for acromegaly-related reasons. In the 12-month post-index period, 37.0% of patients filed claims for acromegaly-related prescription drugs, and patients with greater than 1 claim had an average of 7.6 prescriptions. The most expensive acromegaly-related costs in this study population were inpatient hospitalizations ($6,754) and prescription drugs ($6,147). CONCLUSIONS: Consistent with previous studies, this study confirms that acromegaly is a rare condition associated with multiple comorbidities. Notably, 18.8% of this study population required an inpatient hospital admission during the 12-month post-index period, possibly because of severe comorbidities. Because acromegaly-related costs were driven by hospitalizations and pharmacotherapy, improved management of the disease may reduce the clinical and economic burden experienced by patients with acromegaly.

Cost and consequences of noncompliance to oral bisphosphonate treatment.

BACKGROUND: Despite the favorable efficacy, safety, and cost-effectiveness profile of bisphosphonate (BIS) treatment for osteoporosis (OP), patient compliance remains suboptimal. A longer follow-up period could help to better characterize patient behavior as well as the predictors of noncompliance because of the extended durations of osteoporosis and time to a fracture. OBJECTIVE: To determine health care outcomes associated with compliance and noncompliance to BIS therapy in women diagnosed with OP. METHODS: This retrospective claims study focused on women with OP, who were aged 55 years and older and using oral BIS treatment. Patients were identified within the HealthCore Integrated Research Environment (HIRE) between January 1, 2007, through June 30, 2010. Patients were required to have ≥ 12 months of pre-index eligibility and ≥ 24 months of post-index health plan eligibility. Post-index eligibility was split into 2 periods: (1) the compliance time period (the first 12-month post-index period, in which compliance was determined) and (2) the cost and consequences time period (13- to 24-month post-index period during which time health care resource utilization, cost, and outcomes were assessed). Noncompliance was defined as medical possession ratio (MPR) less than 70%. Descriptive statistics described outcome variables for the study population. A logistic regression model determined variables predictive of compliance. Further, a generalized linear model was used to examine associations between all-cause or OP-related medical/total costs and to estimate health care utilization. RESULTS: Of patients overall (N = 27,905), 59% were noncompliant, and 62% discontinued medication. Among noncompliant patients, 6.7% switched BIS therapy (after 64 days average); 97% discontinued (87 days average); and 21% restarted medication (218 days average). Of noncompliant patients, 14% had greater than 1 inpatient visits; 16% had greater than 1 emergency room visits; 94% had greater than 1 outpatient visits; and 95% had greater than 1 office visits. Logistic regression results indicated that under aged 65 years (P = 0.012) predicted noncompliance. Relative to the compliant group, noncompliant patients had higher fracture rates at post-index second year, 3.3% vs. 2.4%, and combined second and third years, 6.0% vs. 4.8%, respectively. Compared with noncompliant patients, compliant patients had 9% (P = 0.007) lower OP-related costs, 3% lower all-cause costs during the second post-index year, and 11% (P = 0.016) lower OP-related costs. Mean 13- to 24-month post-index period all-cause costs were $7,237 for noncompliant patients versus $6,758 for compliant patients (P = 0.008). CONCLUSIONS: These results indicate high noncompliance rates in this population of older females. OP medication compliance was associated with lower fracture rates, OP- and all-cause costs, and health care utilization. These findings highlight the financial implications and treatment outcomes of BIS medication noncompliance within a female osteoporotic population.

Prior authorization in the treatment of patients with pDPN and FM.

PURPOSE: To determine prior authorization (PA) impact on healthcare utilization, costs, and pharmacologic treatment patterns for painful diabetic peripheral neuropathy (pDPN) and fibromyalgia (FM). METHODS: This retrospective, observational, longitudinal cohort study used medical and pharmacy claims data. Newly diagnosed patients treated for FM or pDPN between 7/1/2007 and 12/31/2011 were included. PA and no PA groups were matched by propensity score 4:1. Medical resource utilization, direct medical and pharmacy costs, and treatment pattern differences were compared. Pre and postindex differences between PA and no PA cohorts were determined by difference in difference analysis. RESULTS: Analysis of 2,315 FM patients (1,852 PA; 463 no PA) demonstrated greater increases in postindex all-cause costs ($197; P = 0.6673) and disease-related costs ($72; P = 0.4186) in the PA cohort. Analysis of 1,300 pDPN patients (1,040 PA; 260 no PA) demonstrated postindex all-cause cost increases of $1,155 more in the no PA cohort (P = 0.6248); disease-related costs decreased $2,809 more in the no PA cohort (P = 0.4312). Treatment patterns were similar between cohorts; opioid usage was higher in the FM PA cohort (P = 0.0082). CONCLUSIONS: There was no evidence of statistically significant differences between PA and no PA cohorts in either FM or pDPN populations for total all-cause or disease-related costs.

Association of age and comorbidity on 2009 influenza A pandemic H1N1-related intensive care unit stay in Massachusetts.

OBJECTIVES: We compared comorbidity measures by age group and risk factors for influenza-like illness (ILI)-related intensive care unit (ICU) stay during the 2009 seasonal influenza and influenza A (pH1N1) pandemic. METHODS: We identified all patients discharged from Massachusetts hospitals with ILI-related diagnoses between October 1, 2008, and April 25, 2009, and pH1N1-related diagnoses between April 26 and September 30, 2009. We calculated the Diagnostic Cost Group (DxCG) risk score as a measure of comorbidity. We used logistic regression predictive models to compare ICU stay predictors. RESULTS: Mean DxCG scores were similar for pH1N1 and seasonal influenza time periods (0.69 and 0.70). Compared with those aged 45 to 64 years, patients younger than 5, 5 to 12, and 13 to 18 years had an increased risk of pH1N1-related ICU stay. Within the pH1N1 cohort, an asthma diagnosis was highly predictive of ICU admission among those younger than 5, 5 to 12, and 13 to 18 years, and pregnancy among those aged 26 to 44 years. CONCLUSION: High-risk groups, including children with asthma or pregnant women, would benefit from improved surveillance and resource allocation during influenza outbreaks to prevent serious ILI-related complications.

Confounding by indication affects antimicrobial risk factors for methicillin-resistant Staphylococcus aureus but not vancomycin-resistant enterococci acquisition.

BACKGROUND: Observational studies rarely account for confounding by indication, whereby empiric antibiotics initiated for signs and symptoms of infection prior to the diagnosis of infection are then viewed as risk factors for infection. We evaluated whether confounding by indication impacts antimicrobial risk factors for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) acquisition. FINDINGS: We previously reported several predictors of MRSA and VRE acquisition in 967 intensive care unit (ICU) patients with no prior history of MRSA or VRE who had an initial negative screening culture followed by either a subsequent negative screening culture (controls) or positive screening or clinical culture (cases). Within and prior to this acquisition interval, we collected demographic, comorbidity, daily device and antibiotic utilization data. We now re-evaluate all antibiotics by medical record review for evidence of treatment for signs and symptoms ultimately attributable to MRSA or VRE. Generalized linear mixed models are used to assess variables associated with MRSA or VRE acquisition, accounting for clustering by ward. We find that exclusion of empiric antibiotics given for suspected infection affects 17% (113/661) of antibiotic prescriptions in 25% (60/244) of MRSA-positive patients but only 1% (5/491) of antibiotic prescriptions in 1% (3/227) of VRE-positive patients. In multivariate testing, fluoroquinolones are no longer associated with MRSA acquisition, and aminoglycosides are significantly protective (OR = 0.3, CI:0.1-0.7). CONCLUSIONS: Neglecting treatment indication may cause common empiric antibiotics to appear spuriously associated with MRSA acquisition. This effect is absent for VRE, likely because empiric therapy is infrequent given the low prevalence of VRE.

Effect of race/ethnicity and socioeconomic status on pandemic H1N1-related outcomes in Massachusetts.

OBJECTIVES: We linked hospital discharge and American Community Survey and US Census data to investigate 2009 H1N1 influenza (H1N1)-related outcomes by racial/ethnic groups and socioeconomic status (SES). METHODS: We examined the population discharged from any acute care hospital in Massachusetts and calculated rates of intensive care unit (ICU) stay by racial/ethnic and SES groups between April 26 and September 30, 2009. We used logistic regression models to identify predictors of ICU stay. RESULTS: Of 4874 H1N1-related hospitalizations, 526 (11%) were admitted to the ICU. Those in less affluent SES groups had lower risk of ICU stay than the most affluent SES group. Compared with Whites, Hispanics had significantly lower risk of 2009 H1N1-related ICU stay (odds ratio = 0.52; 95% confidence interval = 0.32, 0.86). Only 13% of Whites admitted to the ICU were in the lowest SES group, compared with 63% of Hispanics and 43% of Blacks. CONCLUSIONS: To our knowledge, this is the first statewide description of 2009 H1N1 influenza-related ICU stays according to racial/ethnic group and SES in the United States. Future work should investigate evidence related to social determinants of health among racial/ethnic groups to reduce disparities in relation to pandemic influenza.

Colonization with antibiotic-susceptible strains protects against methicillin-resistant Staphylococcus aureus but not vancomycin-resistant enterococci acquisition: a nested case-control study.

INTRODUCTION: Harboring sensitive strains may prevent acquisition of resistant pathogens by competing for colonization of ecological niches. Competition may be relevant to decolonization strategies that eliminate sensitive strains and may predispose to acquiring resistant strains in high-endemic settings. We evaluated the impact of colonization with methicillin-sensitive Staphylococcus aureus (MSSA) and vancomycin-sensitive enterococci (VSE) on acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), respectively, when controlling for other risk factors. METHODS: We conducted a nested case-control study of patients admitted to eight ICUs performing admission and weekly bilateral nares and rectal screening for MRSA and VRE, respectively. Analyses were identical for both pathogens. For MRSA, patients were identified who had a negative nares screen and no prior history of MRSA. We evaluated predictors of MRSA acquisition, defined as a subsequent MRSA-positive clinical or screening culture, compared to those with a subsequent MRSA-negative nares screen within the same hospitalization. Medical records were reviewed for the presence of MSSA on the initial MRSA-negative nares screen, demographic and comorbidity information, medical devices, procedures, antibiotic utilization, and daily exposure to MRSA-positive patients in the same ward. Generalized linear mixed models were used to assess predictors of acquisition. RESULTS: In multivariate models, MSSA carriage protected against subsequent MRSA acquisition (OR = 0.52, CI: 0.29, 0.95), even when controlling for other risk factors. MRSA predictors included intubation (OR = 4.65, CI: 1.77, 12.26), fluoroquinolone exposure (OR = 1.91, CI: 1.20, 3.04), and increased time from ICU admission to initial negative swab (OR = 15.59, CI: 8.40, 28.94). In contrast, VSE carriage did not protect against VRE acquisition (OR = 1.37, CI: 0.54, 3.48), whereas hemodialysis (OR = 2.60, CI: 1.19, 5.70), low albumin (OR = 2.07, CI: 1.12, 3.83), fluoroquinolones (OR = 1.90, CI: 1.14, 3.17), third-generation cephalosporins (OR = 1.89, CI: 1.15, 3.10), and increased time from ICU admission to initial negative swab (OR = 15.13, CI: 7.86, 29.14) were predictive. CONCLUSIONS: MSSA carriage reduced the odds of MRSA acquisition by 50% in ICUs. In contrast, VSE colonization was not protective against VRE acquisition. Studies are needed to evaluate whether decolonization of MSSA ICU carriers increases the risk of acquiring MRSA when discharging patients to high-endemic MRSA healthcare settings. This may be particularly important for populations in whom MRSA infection may be more frequent and severe than MSSA infections, such as ICU patients.

Identification of Influenza Cases During the H1N1 Pandemic in Massachusetts Using Population-Based Hospital Discharge Data.

Objectives(1) To characterize the epidemiology of H1N1-related hospitalizations in Massachusetts; and (2) to compare characteristics of those hospitalized during periods of seasonal influenza activity and during the H1N1 pandemic. MethodsAuthors applied maximum and minimum criteria to the Massachusetts Hospital Discharge Database to identify H1N1-related hospitalizations. They constructed annual line graphs describing mean frequencies of influenza-like illness(ILI)-related discharges between 2005-2008, and compared these rates to early waves of H1N1 in 2009. ResultsDuring spring and summer 2009, there were significantly higher rates of ILI-related hospital discharges in Massachusetts compared to 2005-2008. Out of 359,344 total discharges between April 26-September 30,2009, H1N1-related hospitalizations ranged from 601 to 10,967 cases. Minimum criteria confirmed that H1N1 affected a younger population (50% were <18 years), with higher rates among African-Americans (18%) and Hispanics (23%) and higher rates of ICU admission (21%) compared to seasonal influenza (39%, 10%, 14%, and 17% respectively). ConclusionsThis is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, and it is the first to include all possible hospitalized cases in the analysis. The authors confirm that large administrative data sets can detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending on selection criteria used. Maximum criteria overestimated H1N1 activity, and those meeting minimum criteria resemble published accounts of H1N1-related hospitalizations closely.

Use of Medicare claims to rank hospitals by surgical site infection risk following coronary artery bypass graft surgery.

OBJECTIVE: To evaluate whether longitudinal insurer claims data allow reliable identification of elevated hospital surgical site infection (SSI) rates. DESIGN: We conducted a retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) in US hospitals performing at least 80 procedures in 2005. Hospitals were assigned to deciles by using case mix-adjusted probabilities of having an SSI-related inpatient or outpatient claim code within 60 days of surgery. We then reviewed medical records of randomly selected patients to assess whether chart-confirmed SSI risk was higher in hospitals in the worst deciles compared with the best deciles. PARTICIPANTS: Fee-for-service Medicare beneficiaries who underwent CABG in these hospitals in 2005. RESULTS: We evaluated 114,673 patients who underwent CABG in 671 hospitals. In the best decile, 7.8% (958/12,307) of patients had an SSI-related code, compared with 24.8% (2,747/11,068) in the worst decile ([Formula: see text]). Medical record review confirmed SSI in 40% (388/980) of those with SSI-related codes. In the best decile, the chart-confirmed annual SSI rate was 3.2%, compared with 9.4% in the worst decile, with an adjusted odds ratio of SSI of 2.7 (confidence interval, 2.2-3.3; [Formula: see text]) for CABG performed in a worst-decile hospital compared with a best-decile hospital. CONCLUSIONS: Claims data can identify groups of hospitals with unusually high or low post-CABG SSI rates. Assessment of claims is more reproducible and efficient than current surveillance methods. This example of secondary use of routinely recorded electronic health information to assess quality of care can identify hospitals that may benefit from prevention programs.

The use of immunization registry-based data in vaccine effectiveness studies.

Vaccine effectiveness (VE) studies provide a measure of population-based vaccine performance by combining immunization history data with rates of disease incidence. This review assessed the feasibility of using electronic immunization registry data sources in VE studies. Electronic databases were searched through January 31, 2010. Out of 17 studies, only one paper assessed data accuracy (71%), and three papers assessed population coverage of the registry (estimates ranged from 25% to 90%). This review shows that registry-based data sources can be used to conduct VE studies in a variety of settings and populations. However, we found little information regarding the quality of this data source in VE studies and future evaluations should investigate their reliability, accuracy, and potential bias.

Automated detection of infectious disease outbreaks in hospitals: a retrospective cohort study.

BACKGROUND: Detection of outbreaks of hospital-acquired infections is often based on simple rules, such as the occurrence of three new cases of a single pathogen in two weeks on the same ward. These rules typically focus on only a few pathogens, and they do not account for the pathogens' underlying prevalence, the normal random variation in rates, and clusters that may occur beyond a single ward, such as those associated with specialty services. Ideally, outbreak detection programs should evaluate many pathogens, using a wide array of data sources. METHODS AND FINDINGS: We applied a space-time permutation scan statistic to microbiology data from patients admitted to a 750-bed academic medical center in 2002-2006, using WHONET-SaTScan laboratory information software from the World Health Organization (WHO) Collaborating Centre for Surveillance of Antimicrobial Resistance. We evaluated patients' first isolates for each potential pathogenic species. In order to evaluate hospital-associated infections, only pathogens first isolated >2 d after admission were included. Clusters were sought daily across the entire hospital, as well as in hospital wards, specialty services, and using similar antimicrobial susceptibility profiles. We assessed clusters that had a likelihood of occurring by chance less than once per year. For methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), WHONET-SaTScan-generated clusters were compared to those previously identified by the Infection Control program, which were based on a rule-based criterion of three occurrences in two weeks in the same ward. Two hospital epidemiologists independently classified each cluster's importance. From 2002 to 2006, WHONET-SaTScan found 59 clusters involving 2-27 patients (median 4). Clusters were identified by antimicrobial resistance profile (41%), wards (29%), service (13%), and hospital-wide assessments (17%). WHONET-SaTScan rapidly detected the two previously known gram-negative pathogen clusters. Compared to rule-based thresholds, WHONET-SaTScan considered only one of 73 previously designated MRSA clusters and 0 of 87 VRE clusters as episodes statistically unlikely to have occurred by chance. WHONET-SaTScan identified six MRSA and four VRE clusters that were previously unknown. Epidemiologists considered more than 95% of the 59 detected clusters to merit consideration, with 27% warranting active investigation or intervention. CONCLUSIONS: Automated statistical software identified hospital clusters that had escaped routine detection. It also classified many previously identified clusters as events likely to occur because of normal random fluctuations. This automated method has the potential to provide valuable real-time guidance both by identifying otherwise unrecognized outbreaks and by preventing the unnecessary implementation of resource-intensive infection control measures that interfere with regular patient care. Please see later in the article for the Editors' Summary.