Interfacility Transfer Outcomes Among Children With Complex Chronic Conditions: Associations Between Patient-Level and Hospital-Level Factors and Transfer Outcomes.

OBJECTIVES: Determine patient- and referring hospital-level predictors of transfer outcomes among children with 1 or more complex chronic conditions (CCCs) transferred to a large academic medical center. METHODS: We conducted a retrospective chart review of 2063 pediatric inpatient admissions from 2017 to 2019 with at least 1 CCC defined by International Classification of Diseases, Tenth Revision codes. Charts were excluded if patients were admitted via any route other than transfer from a referring hospital's emergency department or inpatient ward. Patient-level factors were race/ethnicity, payer, and area median income. Hospital-level factors included the clinician type initiating transfer and whether the referring-hospital had an inpatient pediatric ward. Transfer outcomes were rapid response within 24 hours of admission, Pediatric Early Warning Score at admission, and hours to arrival. Regression analyses adjusted for age were used to determine association between patient- and hospital-level predictors with transfer outcomes. RESULTS: There were no significant associations between patient-level predictors and transfer outcomes. Hospital-level adjusted analyses indicated that transfers from hospitals without inpatient pediatrics wards had lower odds of ICU admission during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.97) and shorter transfer times (ß-coefficient, -2.54; 95% CI, -3.60 to -1.49) versus transfers from hospitals with inpatient pediatrics wards. There were no significant associations between clinician type and transfer outcomes. CONCLUSIONS: For pediatric patients with CCCs, patient-level predictors were not associated with clinical outcomes. Transfers from hospitals without inpatient pediatric wards were less likely to require ICU admission and had shorter interfacility transfer times compared with those from hospitals with inpatient pediatrics wards.

Translating ethical and quality principles for the effective, safe and fair development, deployment and use of artificial intelligence technologies in healthcare.

OBJECTIVE: The complexity and rapid pace of development of algorithmic technologies pose challenges for their regulation and oversight in healthcare settings. We sought to improve our institution's approach to evaluation and governance of algorithmic technologies used in clinical care and operations by creating an Implementation Guide that standardizes evaluation criteria so that local oversight is performed in an objective fashion. MATERIALS AND METHODS: Building on a framework that applies key ethical and quality principles (clinical value and safety, fairness and equity, usability and adoption, transparency and accountability, and regulatory compliance), we created concrete guidelines for evaluating algorithmic technologies at our institution. RESULTS: An Implementation Guide articulates evaluation criteria used during review of algorithmic technologies and details what evidence supports the implementation of ethical and quality principles for trustworthy health AI. Application of the processes described in the Implementation Guide can lead to algorithms that are safer as well as more effective, fair, and equitable upon implementation, as illustrated through 4 examples of technologies at different phases of the algorithmic lifecycle that underwent evaluation at our academic medical center. DISCUSSION: By providing clear descriptions/definitions of evaluation criteria and embedding them within standardized processes, we streamlined oversight processes and educated communities using and developing algorithmic technologies within our institution. CONCLUSIONS: We developed a scalable, adaptable framework for translating principles into evaluation criteria and specific requirements that support trustworthy implementation of algorithmic technologies in patient care and healthcare operations.

Impact of a hospital service for adults with chronic childhood-onset disease: A propensity weighted analysis.

BACKGROUND: Young adults with chronic childhood-onset diseases (CCOD) transitioning care from pediatrics to adult care are at high risk for readmission after hospital discharge. At our institution, we have implemented an inpatient service, the Med-Peds (MP) line, to improve transitions to adult care and reduce hospital utilization by young adults with CCOD. OBJECTIVE: This study aimed to assess the effect of the MP line on length of stay (LOS) and 30-day readmission rates compared to other inpatient services. METHODS: This was an observational, retrospective cohort analysis of patients admitted to the MP line compared to other hospital service lines over a 2-year period. To avoid potential confounding by indication for admission to the MP line, propensity score weighting methods were used. RESULTS: The MP line cared for 302 patients with CCOD from June 2019 to July 2021. Compared to other service lines, there was a 33% reduction in relative risk of 30-day readmission (26.9% compared to 40.3%, risk ratio = 0.67, 95% confidence interval [CI] 0.55-0.81). LOS was 10% longer for the MP line (event time ratio (ETR): 1.10 95% CI 1.0-1.21) with median LOS 4.8 versus 4.5 days. Patients with sickle cell disease had less of a reduction in 30-day readmissions and longer LOS. CONCLUSION: Hospitalization for young adults with CCOD on a MP service line was associated with lower 30-day readmission rates and longer LOS than hospitalization on other services. Further research is needed to assess which components of the line most contribute to decreased utilization.

Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study.

BACKGROUND: Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. OBJECTIVE: This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. METHODS: This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. RESULTS: Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. CONCLUSIONS: Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. TRIAL REGISTRATION: ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46847.

Catalyzing Cross-Sector Collaboration: Lessons from a Virtual Pediatric Complex Care Coalition.

BACKGROUND: Children with complex health needs (CCHN) have intersecting medical, behavioral health, and social needs. Unfortunately, fragmentation across health and social services sectors often results in uncoordinated care for CCHN and their families. OBJECTIVE: The purpose of this article is to describe the creation of a statewide cross-sector partnership, the Children's Complex Care Coalition of North Carolina, to identify and act on opportunities for system-level improvements in the care of CCHN. METHODS: We applied a virtual community engagement approach to form an advisory committee of cross-sector collaborators; systematically identify priorities most important and urgent to collaborators for improving systems of care; and host a series of virtual convenings involving more than 90 attendees from across the state to operationalize collaborator-identified priorities into actionable next steps. LESSONS LEARNED: Key facilitators of success for the Children's Complex Care Coalition of North Carolina partnership were investing time in building trusting relationships, particularly with families of CCHN, and aligning goals and priorities with existing local and regional efforts. Challenges included incorporating traditionally under-represented perspectives, right-sizing virtual convening attendance and number of topics covered, and navigating technological difficulties in a virtual environment. CONCLUSIONS: Health systems can catalyze the formation of cross-sector coalitions and community partnerships to advance complex care. Virtual convenings with interactive activities and participatory structures can be an efficient medium to connect coalition members and elicit actionable recommendations for system-level improvements that address the needs of community members.

Predictive Modeling to Identify Children With Complex Health Needs At Risk for Hospitalization.

BACKGROUND: Identifying children at high risk with complex health needs (CCHN) who have intersecting medical and social needs is challenging. This study's objectives were to (1) develop and evaluate an electronic health record (EHR)-based clinical predictive model ("model") for identifying high-risk CCHN and (2) compare the model's performance as a clinical decision support (CDS) to other CDS tools available for identifying high-risk CCHN. METHODS: This retrospective cohort study included children aged 0 to 20 years with established care within a single health system. The model development/validation cohort included 33 months (January 1, 2016-September 30, 2018) and the testing cohort included 18 months (October 1, 2018-March 31, 2020) of EHR data. Machine learning methods generated a model that predicted probability (0%-100%) for hospitalization within 6 months. Model performance measures included sensitivity, positive predictive value, area under receiver-operator curve, and area under precision-recall curve. Three CDS rules for identifying high-risk CCHN were compared: (1) hospitalization probability ≥10% (model-predicted); (2) complex chronic disease classification (using Pediatric Medical Complexity Algorithm [PMCA]); and (3) previous high hospital utilization. RESULTS: Model development and testing cohorts included 116 799 and 27 087 patients, respectively. The model demonstrated area under receiver-operator curve = 0.79 and area under precision-recall curve = 0.13. PMCA had the highest sensitivity (52.4%) and classified the most children as high risk (17.3%). Positive predictive value of the model-based CDS rule (19%) was higher than CDS based on the PMCA (1.9%) and previous hospital utilization (15%). CONCLUSIONS: A novel EHR-based predictive model was developed and validated as a population-level CDS tool for identifying CCHN at high risk for future hospitalization.

Caregiver Perspectives on Telemedicine for Postdischarge Care for Children With Medical Complexity: A Qualitative Study.

INTRODUCTION: The objectives of this study were to describe the perspectives of caregivers of children with medical complexity on telemedicine video visits (TMVV) for posthospitalization care and determine whether TMVV may be a viable alternative to in-person follow-up. METHOD: Our qualitative descriptive study included semistructured telephone interviews with 12 caregivers. Data analysis was conducted using an adapted Colaizzi's descriptive phenomenological method for thematic construction. RESULTS: Results were organized into four themes describing caregivers' experiences with TMVV: (1) promoted caregiver self-efficacy and sense of independence; (2) TMVV as convenient, cost-effective, comprehensive, and acceptable; (3) supported caregiver decision-making and problem-solving; and (4) fostered delivery of family-centered care. DISCUSSION: Although in-person visits are necessary for some circumstances, TMVV can serve as a convenient and acceptable alternative for posthospitalization follow-up in children with medical complexity. Overall, caregivers in this study were satisfied with the quality of care and individualized experience of TMVV.

Healthcare Utilization for Medicaid-Insured Children with Medical Complexity: Differences by Sociodemographic Characteristics.

OBJECTIVE: To compare differences in healthcare utilization and costs for Medicaid-insured children with medical complexity (CMC) by race/ethnicity and rurality. METHODS: Retrospective cohort of North Carolina (NC) Medicaid claims for children 3-20 years old with 3 years continuous Medicaid coverage (10/1/2015-9/30/2018). Exposures were medical complexity, race/ethnicity, and rurality. Three medical complexity levels were: without chronic disease, non-complex chronic disease, and complex chronic disease; the latter were defined as CMC. Race/ethnicity was self-reported in claims; we defined rurality by home residence ZIP codes. Utilization and costs were summarized for 1 year (10/1/2018-9/30/2019) by complexity level classification and categorized as acute care (hospitalization, emergency [ED]), outpatient care (primary, specialty, allied health), and pharmacy. Per-complexity group utilization rates (per 1000 person-years) by race/ethnicity and rurality were compared using adjusted rate ratios (ARR). RESULTS: Among 859,166 Medicaid-insured children, 118,210 (13.8%) were CMC. Among CMC, 36% were categorized as Black non-Hispanic, 42.7% White non-Hispanic, 14.3% Hispanic, and 35% rural. Compared to White non-Hispanic CMC, Black non-Hispanic CMC had higher hospitalization (ARR = 1.12; confidence interval, CI 1.08-1.17) and ED visit (ARR = 1.17; CI 1.16-1.19) rates; Hispanic CMC had lower ED visit (ARR = 0.77; CI 0.75-0.78) and hospitalization rates (ARR = 0.79; CI 0.73-0.84). Black non-Hispanic and Hispanic CMC had lower outpatient visit rates than White non-Hispanic CMC. Rural CMC had higher ED (ARR = 1.13; CI 1.11-1.15) and lower primary care utilization rates (ARR = 0.87; CI 0.86-0.88) than urban CMC. DISCUSSION: Healthcare utilization varied by race/ethnicity and rurality for Medicaid-insured CMC. Further studies should investigate mechanisms for these variations and expand higher value, equitable care delivery for CMC.

A Tailored SMS Text Message-Based Intervention to Facilitate Patient Access to Referred Community-Based Social Needs Resources: Protocol for a Pilot Feasibility and Acceptability Study.

BACKGROUND: Health care providers are increasingly screening patients for unmet social needs (eg, food, housing, transportation, and social isolation) and referring patients to relevant community-based resources and social services. Patients' connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. SMS text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner. OBJECTIVE: In this multi-methods pilot study, we aim to develop an automated SMS text message-based intervention to promote patient connection to referred social needs resources within 2 weeks of the initial referral and to evaluate its feasibility and patient acceptability. This protocol describes the intervention, conceptual underpinnings, study design, and evaluation plan to provide a detailed illustration of how SMS technology can complement current social needs screening and referral practice patterns without disrupting care. METHODS: For this pilot prospective cohort study, this SMS text message-based intervention augments an existing social needs screening, referral, and navigation program at a federally qualified health center. Patients who received at least one referral for any identified unmet social need are sent 2 rounds of SMS messages over 2 weeks. The first round consists of 5-10 messages that deliver descriptions of and contact information for the referred resources. The second round consists of 2 messages that offer a brief reminder to contact the resources. Participants will evaluate the intervention via a survey and a semistructured interview, informed by an adapted technology acceptance model. Rapid qualitative and thematic analysis will be used to extract themes from the responses. Primary outcomes are implementation feasibility and patient acceptability. Secondary outcomes relate to intervention effectiveness: self-reported attempt to connect and successful connection to referred resources 2 weeks after the initial referral encounter. RESULTS: The study received regulatory approval in May 2021, and we anticipate enrolling 15-20 participants for this initial pilot. CONCLUSIONS: This protocol presents detailed implementation methods about a novel automated SMS intervention for social care integration within primary care. By sharing the study protocol early, we intend to facilitate the development and adoption of similar tools across different clinical settings, as more health care providers seek to address the unmet social needs of patients. Study findings will provide practical insights into the design and implementation of SMS text message-based interventions to improve social and medical care coordination. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37316.

Redesigning Care of Hospitalized Young Adults With Chronic Childhood-Onset Disease.

Background Young adults with chronic childhood-onset disease (CCOD) are routinely admitted to internal medicine hospitalist services, yet most lack transition preparation to adult care. Providers and patients feel the strain of admissions to adult services in part due to their medical and social complexity. Methods We performed a descriptive study of a care redesign project for young adults with CCOD hospitalized at a large, tertiary care academic hospital. We describe the process of implementation of the Med-Peds (MP) service line and characterize patients cared for by the service. We measured and analyzed patient demographics, process implementation, healthcare screening, and healthcare utilization data. Results During the 16 months of the study period, 254 patients were cared for by the MP service line, accounting for 385 hospitalizations. The most common CCODs were sickle cell disease (22.4%) and type 1 diabetes (14.6%). The majority (76%) of patients completed transition readiness assessment, and 38.6% completed social determinant of health (SDH) screening during their admission. Patients had high prevalence of SDH with 66.7% having an unmet social need. The average length of stay was 6.6 days and the average 30-day readmission rate was 20.0%. Conclusions There is opportunity to redesign the inpatient care of young adult patients with CCOD. The MP service line is a care model that can be integrated into existing hospital medicine teams with MP physicians. Hospitals should consider redesigning care for young adults with CCOD to meet the transitional and social needs unique to this patient population.

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement.

OBJECTIVE: Children with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings. METHODS: We surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority. RESULTS: Forty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce. CONCLUSIONS: Priorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.

Feasibility of Post-hospitalization Telemedicine Video Visits for Children With Medical Complexity.

OBJECTIVES: To evaluate feasibility and acceptability of post-hospitalization telemedicine video visits (TMVV) during hospital-to-home transitions for children with medical complexity (CMC); and explore associations with hospital utilization, caregiver self-efficacy (CSE), and family self-management (FSM). METHOD: This non-randomized pilot study assigned CMC (n=28) to weekly TMVV for four weeks post-hospitalization; control CMC (n=20) received usual care without telemedicine. Feasibility was measured by time to connection and proportion of TMVV completed; acceptability was measured by parent-reported surveys. Pre/post-discharge changes in CSE, FSM, and hospital utilization were assessed. RESULTS: 64 TMVV were completed; 82 % of patients completed 1 TMVV; 54 % completed four TMVV. Median time to TMVV connection was 1 minute (IQR=2.5). Parents reported high acceptability of TMVV (mean 6.42; 1 -7 scale). CSE and FSM pre/post-discharge were similar for both groups; utilization declined in both groups post-discharge. DISCUSSION: Post-hospitalization TMVV for CMC were feasible and acceptable during hospital-to-home transitions.

Feasibility of implementing systematic social needs assessment for children with medical complexity.

BACKGROUND: Children with medical complexity (CMC) have inter-related health and social needs; however, interventions to identify and respond to social needs have not been adapted for CMC. The objective of this study was to evaluate the feasibility of implementing social needs screening and assessment within pediatric complex care programs. METHODS: We implemented systematic social needs assessment for CMC (SSNAC) at two tertiary care centers in three phases: (1) pre-implementation, (2) implementation, and (3) implementation monitoring. We utilized a multifaceted implementation package consisting of discrete implementation strategies within each phase. In phase 1, we adapted questions from evidence-informed screening tools into a 21-item SSNAC questionnaire, and we used published frameworks to inform implementation readiness and process. In phases 2-3, clinical staff deployed the SSNAC questionnaire to parents of CMC in-person or by phone as part of usual care and adapted to local clinical workflows. Staff used shared decision-making with parents and addressed identified needs by providing information about available resources, offering direct assistance, and making referrals to community agencies. Implementation outcomes included fidelity, feasibility, acceptability, and appropriateness. RESULTS: Observations from clinical staff characterized fidelity to use of the SSNAC questionnaire, assessment template, and shared decision-making for follow-up on unmet social needs. Levels of agreement (5-point Likert scale; 1 = completely disagree; 5 = completely agree) rated by staff for key implementation outcomes were moderate to high for acceptability (mean = 4.7; range = 3-5), feasibility (mean = 4.2; range = 3-5), and appropriateness (mean = 4.6; range = 4-5). 49 SSNAC questionnaires were completed with a 91% response rate. Among participating parents, 37 (76%) reported ≥ 1 social need, including food/nutrition benefits (41%), housing (18%), and caregiver needs (29%). Staff responses included information provision (41%), direct assistance (30%), and agency referral (30%). CONCLUSIONS: It was feasible for tertiary care center-based pediatric complex care programs to implement a standardized social needs assessment for CMC to identify and address parent-reported unmet social needs.

Mobile Complex Care Plans to Enhance Parental Engagement for Children With Medical Complexity.

Care plans can reduce care fragmentation for children with medical complexity (CMC); however, implementation is challenging. Mobile health innovations could improve implementation. This mixed methods study's objectives were to (1) evaluate feasibility of mobile complex care plans (MCCPs) for CMC enrolled in a complex care program and (2) study MCCPs' impact on parent engagement, parent experience, and care coordination. MCCPs were individualized, updated quarterly, integrated within the electronic health record, and visible on parents' mobile devices via an online portal. In 1 year (September 1, 2016, to August 31, 2017), 94% of eligible patients (n = 47) received 162 MCCPs. Seventy-four percent of parents (n = 35) reviewed MCCPs online. Forty-six percent of these parents (n = 16) sent a follow-up message, and the care team responded within 8 hours (median time = 7.2 hours). In interviews, parents identified MCCPs as an important reference and communication tool. MCCPs for CMC in a complex care program were feasible, facilitated parental engagement, and delivered timely communication.

The Impact of Hospital Health Network Affiliation on Discharge Communication Preferences of Primary Care Providers.

Primary care physicians (PCPs) experience differential postdischarge access to electronic health records, depending upon affiliation with the discharging hospital's health network. To better understand whether this affiliation impacts discharge communication preferences, we surveyed a convenience sample of PCPs in and out of our hospital's health network. We also surveyed hospitalists and compared PCPs' and hospitalists' responses. We found that PCP discharge communication preferences differed by hospital health network affiliation. In addition, PCPs and hospitalists reported different expectations of responsibility for pending laboratory test follow-up. More inclusive communication strategies and standardization of responsibility for pending laboratory results may improve discharge communication quality.

CaPOW! Using Problem Sets in a Capstone Course to Improve Fourth-Year Medical Students' Confidence in Self-Directed Learning.

PROBLEM: Despite the importance of self-directed learning (SDL) in the field of medicine, individuals are rarely taught how to perform SDL or receive feedback on it. Trainee skill in SDL is limited by difficulties with self-assessment and goal setting. APPROACH: Ninety-two graduating fourth-year medical students from Duke University School of Medicine completed an individualized learning plan (ILP) for a transition-to-residency Capstone course in spring 2015 to help foster their skills in SDL. Students completed the ILP after receiving a personalized report from a designated faculty coach detailing strengths and weaknesses on specific topics (e.g., pulmonary medicine) and clinical skills (e.g., generating a differential diagnosis). These were determined by their performance on 12 Capstone Problem Sets of the Week (CaPOWs) compared with their peers. Students used transitional-year milestones to self-assess their confidence in SDL. OUTCOMES: SDL was successfully implemented in a Capstone course through the development of required clinically oriented problem sets. Coaches provided guided feedback on students' performance to help them identify knowledge deficits. Students' self-assessment of their confidence in SDL increased following course completion. However, students often chose Capstone didactic sessions according to factors other than their CaPOW performance, including perceived relevance to planned specialty and session timing. NEXT STEPS: Future Capstone curriculum changes may further enhance SDL skills of graduating students. Students will receive increased formative feedback on their CaPOW performance and be incentivized to attend sessions in areas of personal weakness.

The impact of depth of infection and postdischarge surveillance on rate of surgical-site infections in a network of community hospitals.

OBJECTIVE: To describe the epidemiology of surgical-site infections (SSIs) in community hospitals and to explore the impact of depth of SSI, healthcare location at the time of diagnosis, and variations in surveillance practices on the overall rate of SSI. DESIGN: Retrospective cohort study. SETTING: Thirty-seven community hospitals in the southeastern United States. PATIENTS: Consecutive sample of patients undergoing surgical procedures between July 1, 2007, and December 31, 2008. METHODS: ANOVA was used to compare rates of SSIs, and the F test was used to compare the distribution of rates of SSIs. Wilcoxon Signed Rank test [corrected] was used to test for differences in performance rankings of hospitals. RESULTS: Following 177,706 surgical procedures, 1,919 SSIs were identified (incidence, 1.08 per 100 procedures). Sixty-four percent (1,223 of 1,919) of these were identified as complex SSIs; 87% of the complex SSIs were diagnosed in inpatient settings. The median proportion of superficial-incisional SSIs was 37% (interquartile range, 29.6%-49.5%). Postdischarge SSI surveillance was variable, with 58% of responding hospitals using surgeon letters. As reporting focus was narrowed from all SSIs to complex SSIs (incidence, 0.69 per 100 procedures) and, finally, to complex SSIs diagnosed in the inpatient setting (incidence, 0.51 per 100 procedures), variance in rates changed significantly ([Formula: see text]). Performance ranking of individual hospitals, based on rates of SSIs, differed significantly, depending on the reporting method utilized ([Formula: see text]). CONCLUSIONS: Inconsistent reporting methods focused on variable depths of infection and healthcare location at time of diagnosis significantly impact rates of SSI, distribution of rates of SSI, and hospital comparative-performance rankings. We believe that public reporting of SSI rates should be limited to complex SSIs diagnosed in the inpatient setting.