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1.
Am J Manag Care ; 26(3): e84-e90, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32181620

RESUMO

OBJECTIVES: Hospitals have begun designing programs tailored to patients with intellectual disabilities to address their specific healthcare needs and social determinants of health. This study aimed to determine whether these programs improve hospital outcomes for patients with intellectual disabilities. STUDY DESIGN: This cross-sectional, retrospective study analyzed data for patients with a primary or secondary diagnosis of intellectual disability and/or autism who were discharged from 5 hospitals participating in Vizient's Clinical Data Base/Resource Manager between January 2010 and September 2018. METHODS: Generalized linear regression models were constructed to test the association between tailored program status and length of stay, cost, and cost per day, and a binary logistic regression model was constructed to test the association between tailored program status and 30-day readmission. A secondary analysis stratified patients by 3M All Patient Refined Diagnosis Related Groups grouper (the standard for inpatient classification) admission severity of illness (ASOI) score. RESULTS: Of the 6618 patients included in the study, 29% were treated at hospitals with tailored programs. After controlling for patient demographic characteristics and clinical factors, patients treated at hospitals without programs had higher total costs (relative risk [RR], 1.06; P = .038) and cost per day (RR, 1.11; P <.001). Patients with an extreme ASOI score who were treated at hospitals without programs had significantly longer stays (RR, 1.38; P = .001), higher total cost (RR, 1.42; P <.001), and higher cost per day (RR, 1.10; P = .025) than patients treated at hospitals with programs. CONCLUSIONS: Providing tailored programs for patients with intellectual disabilities is a promising strategy for improving inpatient care for this population.

3.
Clin Infect Dis ; 2020 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-32107536

RESUMO

BACKGROUND: Ceftazidime-avibactam has in vitro activity against some carbapenem-resistant gram-negative infections (GNIs), and therefore may be a useful alternative to more toxic antibiotics such as colistin. Understanding ceftazidime-avibactam uptake and usage patterns would inform hospital formularies, stewardship, and antibiotic development. METHODS: A retrospective cohort study assessed inpatient encounters in the Vizient database. Ceftazidime-avibactam and colistin administrations were categorized into presumed empiric (3 consecutive days of therapy or less with qualifying exclusions) versus targeted therapy (≥4 consecutive days of therapy) for presumed carbapenem-resistant GNIs. Quarterly percentage change (QPC) using modified Poisson regression and relative change in frequency of targeted ceftazidime-avibactam to colistin encounters was calculated. Factors associated with preferentially receiving targeted ceftazidime-avibactam versus colistin were identified using generalized estimating equations. RESULTS: Between 2015 quarter (q) 1 and 2017q4, ceftazidime-avibactam was administered 21 215 times across 1901 encounters. Inpatient prescriptions for ceftazidime-avibactam increased from 0.44/10 000 hospitalizations in 2015q1 to 7.7/10 000 in 2017q4 (QPC, +11%; 95% CI, 10-13%; P < .01), while conversely colistin prescriptions decreased quarterly by 5% (95% CI, 4-6%; P < .01). Ceftazidime-avibactam therapy was categorized as empiric 25% of the time, targeted 65% of the time, and indeterminate 10% of the time. Patients with chronic kidney disease were twice as likely to receive targeted ceftazidime-avibactam versus colistin (RR, 2.02; 95% CI, 1.82-2.25), whereas those on dialysis were less likely to receive ceftazidime-avibactam than colistin (RR, 0.71; 95% CI, .61-.83). CONCLUSIONS: Since approval in 2015, ceftazidime-avibactam use has grown for presumed carbapenem-resistant GNIs, while colistin has correspondingly declined. Renal function drove the choice between ceftazidime-avibactam and colistin as targeted therapy.

4.
J Healthc Manag ; 65(1): 30-43, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31913237

RESUMO

EXECUTIVE SUMMARY: Expanding hospitals' geographic market area has been proposed as a means to increase competition and reduce healthcare costs. However, most patients in the United States receive care locally and are unlikely to seek out distant hospitals, effectively limiting competition to local markets. We hypothesize that mass media advertising can help overcome patients' reluctance to travel for elective medical care. We examined hospitals' advertising in distant markets to determine whether their expenditures predict the number of patients who travel to those hospitals.We obtained data on 2015 advertising expenditures by 273 U.S. academic medical centers from a market research firm. Regression models examined associations between hospitals' advertising expenditures and patient volume metrics: inpatients, encounters, and charges originating from distant markets where the medical centers advertised. Results showed that hospitals' advertising expenditures in distant markets were associated with higher numbers of inpatient admissions, patient visits, and charges from those markets. Compared to the distant markets where they advertised, the hometown markets of these hospitals are smaller with lower per capita income, suggesting hospitals are seeking incremental patient volume from more lucrative markets.Findings suggest that advertising may familiarize patients with distant facilities, encouraging domestic medical travel and enabling broader geographic competition among hospitals.

5.
Clin Neurol Neurosurg ; 188: 105585, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31756619

RESUMO

OBJECTIVE: Overlapping surgery, accepted by many as two distinct operations occurring at the same time but without coincident critical portions, has been said to improve patient access to surgical care. With recent controversy, some are opposed to this practice due to concerns regarding its safety. In this manuscript, we sought to investigate the perceptions of overlapping surgery among neurosurgical leadership and the association of these perceptions with neurosurgical case volume. PATIENTS AND METHODS: We conducted a self-administered survey of neurosurgery department chair and residency program directors of institutions participating in the Vizient Clinical Database/Resource (CDB/RM), an administrative database of 117 United States (US) medical centers and their 300 affiliated hospitals. We queried participants regarding yearly departmental case-volume, frequency of overlapping surgery in daily practice and the degree of overlapping they find acceptable. RESULTS: Of the 236 surveys disseminated, a total of 70 responses were received with a response rate of 29.7.%, which is comparable to previously reported response rates among neurosurgeons and other physicians. Our respondents consisted of 43 of 165 chairs (26.1.%) and 27 of 66 program directors (40.0.%) representing 64 unique hospitals/institutions out of 216 (29.6.%). Based on the responses to question involving case volume, we divided our responders into high volume hospitals (HVH) (n = 44; > 2000 cases per year) and low volume hospitals (LVH) (N = 26). More HVH were found to have frequent occurrence of overlapping surgery (50% weekly and 20.9.% daily vs LVH's 26.9.% weekly and 3.8.% daily, p = 0.003) and considered two overlapping surgeries without overlap of critical portion as acceptable (38.6.% vs 26.9.%, p = 0.10). CONCLUSIONS: Our survey results showed that neurosurgical departments with high-volume practices were more likely to practice overlapping surgery on a regular basis and to view it as an acceptable practice. The association between overlapping surgery and the volume-outcome relationship should be further evaluated.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31375378

RESUMO

OBJECTIVE: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. METHODS: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. RESULTS: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. CONCLUSIONS: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

7.
Infect Control Hosp Epidemiol ; 40(9): 1050-1052, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31232263

RESUMO

We used multivariable analyses to assess whether meeting core elements was associated with antibiotic utilization. Compliance with 7 elements versus not doing so was associated with higher use of broad-spectrum agents for community-acquired infections [days of therapy per 1,000 patient days: 155 (39) vs 133 (29), P = .02] and anti-methicillin-resistant S. aureus agents [days of therapy per 1,000 patient days: 145 (37) vs 124 (30), P = .03].

8.
Contraception ; 100(2): 111-115, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31051117

RESUMO

OBJECTIVE: To identify the nationwide rate of salpingectomy for permanent contraception before and after the January 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion, Salpingectomy for Ovarian Cancer Prevention. STUDY DESIGN: Using ICD-9/10 diagnosis and procedure codes within the Vizient database, we identify permanent contraception procedures with and without salpingectomy, among females 18-50 years old between January 2013 and January 2017. Subject, hospital characteristics and costs information were recorded. To determine the changes in salpingectomy rates over time analysis was conducted using the Cochran-Armitage trend test and logistic regression models. RESULTS: A total of 211,312 women across 303 Vizient-member hospitals underwent a permanent contraception procedure over the study period. Of these, 174,930 subjects were selected from 160 hospitals that contributed data over the full 49-month period. Overall, 25,882 (14.8%) subjects underwent a salpingectomy for an indication of permanent contraception. Higher salpingectomy rates were identified among larger (p<.0001), teaching (p<.0001) hospitals versus smaller, non-teaching hospitals and in subjects with commercial/private payers (p<.0001). A lower salpingectomy rate was observed in Northeast hospitals (p<.0001). Median total hospital costs differed by $25 between permanent contraceptions performed with and without salpingectomy. The proportion of salpingectomies was <1% in January 2013 slowly rising to 20.6% in October 2015 and then 61.5% by January 2017 (p<.0001). During the pre-opinion period (Jan 2013-Dec 2014) the monthly increase in the odds of salpingectomy was 6% (OR 1.06, 95% CI 1.05, 1.06) compared to a monthly increase of 18% (OR 1.18, 95% CI 1.18, 1.18) during the post-opinion period (Jan 2015-Jan 2017). CONCLUSIONS: The nationwide rate of salpingectomies for permanent contraception has steadily increased among Vizient-member hospitals since the ACOG committee opinion. IMPLICATIONS: Salpingectomy as an approach to permanent contraception in the United States is increasing since the ACOG Committee Opinion with differing utilization rates by hospital type, region, size, and patient payer types. Physician behavior may be influenced by practice guidelines but other factors mitigate the effect.

9.
Am J Infect Control ; 47(9): 1040-1047, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30824387

RESUMO

BACKGROUND: Tracer antibiotic algorithms using administrative data were investigated to estimate mortality attributable to extensively drug-resistant gram-negative infections (GNIs). METHODS: Among adult inpatients coded for GNIs, colistin cases and 2 comparator cohorts (non-carbapenem ß-lactams or carbapenems) treated for ≥4 consecutive days, or died while receiving the antibiotic, were separately propensity score-matched (1:2). Attributable mortality was the in-hospital mortality difference among propensity-matched groups. Infection characteristics and sepsis severity influences on attributable mortality were examined. Algorithm accuracy was assessed by chart review. RESULTS: Of 232,834 GNIs between 2010 and 2013 at 79 hospitals, 1,023 per 3,350 (30.5%) colistin and 9,188 per 105,641 (8.7%) ß-lactam (non-carbapenem) comparator cases died. Propensity-matched colistin and ß-lactam case mortality was 29.2% and 16.6%, respectively, for an attributable mortality of 12.6% (95% confidence interval 10.8-14.4%). Attributable mortality varied from 11.0% (7.5%-14.7%) for urinary to 15.5% (12.6%-18.4%) for respiratory (P < .0001), and 4.6% (2.1%-7.4%) for early (≤4 days) to 16.6% (14.3%-18.9%) for late-onset infections (P < .0001). Attributable mortality decreased to 7.5% (5.6%-9.4%) using a carbapenem comparator cohort but increased 9-fold in patients coded for severe sepsis or septic shock (P < .0001). Our colistin algorithm had a positive predictive value of 60.4% and sensitivity of 65.3%. CONCLUSIONS: Mortality attributable to treatment-limiting resistance during GNIs varied considerably by site, onset, and severity of infection.

10.
Am J Infect Control ; 47(2): 217-219, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30220616

RESUMO

Patients with cancer are vulnerable to Clostridium difficile infection (CDI); hospitals with larger oncology populations may have worse CDI performance. Among 71 academic hospitals studied, there were significant differences in oncology patient-days per 1,000 admissions across CDI standardized infection ratio categories of better, no different, and worse; worse hospitals had the greatest number of patient-days. Oncology patients' most commonly used high-risk CDI medications were quinolones, third- and fourth-generation cephalosporins, and proton pump inhibitors.

11.
J Neurosurg Spine ; 29(6): 687-695, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30215589

RESUMO

OBJECTIVEFrom 1994 to 2006 outpatient spinal surgery increased 5-fold. The perceived cost savings with outcomes comparable to or better than those achieved with inpatient admission for the same procedures are desirable in an era where health expenditures are scrutinized. The increase in outpatient spine surgery is also driven by the proliferation of ambulatory surgery centers. In this study, the authors hypothesized that the total savings in outpatient spine surgery is largely driven by patient selection and biases toward healthier patients.METHODSA meta-analysis assessed patient selection factors and outcomes associated with outpatient spine procedures. Pooled odds ratios and mean differences were calculated using a Bayesian random-effects model. The authors extended this analysis in a novel way by using the results of the meta-analysis to examine cost data from an administrative database of academically affiliated hospitals. A Bayesian approach with priors informed by the meta-analysis was used to compare costs for inpatient and outpatient performance of anterior cervical discectomy and fusion (ACDF) and lumbar laminectomy.RESULTSSixteen studies with a total of 370,195 patients met the inclusion criteria. Outpatient procedures were associated with younger patient age (mean difference [MD] -2.34, 95% credible interval [CrI] -4.39 to -0.34) and no diabetes diagnosis (odds ratio [OR] 0.78, 95% CrI 0.54-0.97). Outpatient procedures were associated with a lower likelihood of reoperation (OR 0.42, 95% CrI 0.16-0.80), 30-day readmission (OR 0.39, 95% CrI 0.16-0.74), and complications (OR 0.29, 95% CrI 0.15-0.50) and with lower overall costs (MD -$121,392.72, 95% CrI -$216,824.81 to -$23,632.92). Additional analysis of the national administrative data revealed more modest cost savings than those found in the meta-analysis for outpatient spine surgeries relative to inpatient spine surgeries. Estimated cost savings for both younger patients ($555 for those age 30-35 years [95% CrI -$733 to -$374]) and older patients ($7290 for those age 65-70 years [95% CrI -$7380 to -$7190]) were less than the overall cost savings found in the meta-analysis.CONCLUSIONSCompared to inpatient spine surgery, outpatient spine surgery was associated with better short-term outcomes and an initial reduction in direct costs. A selection bias for outpatient procedures toward younger, healthier patients may confound these results. The additional analysis of the national database suggests that cost savings in the outpatient setting may be less than previously reported and a result of outpatient procedures being offered more frequently to younger and healthier individuals.


Assuntos
Redução de Custos/estatística & dados numéricos , Seleção de Pacientes , Complicações Pós-Operatórias/economia , Reoperação/economia , Procedimentos Cirúrgicos Ambulatórios , Humanos , Pacientes Ambulatoriais/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Reoperação/efeitos adversos
12.
Crit Care Med ; 46(10): 1563-1569, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30179886

RESUMO

OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes. DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline). SETTING: Administrative claims data collected from medical centers across the United States (Vizient). PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day. INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit. MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation. CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.


Assuntos
Unidades de Terapia Intensiva/legislação & jurisprudência , Relações Enfermeiro-Paciente , Recursos Humanos de Enfermagem no Hospital/legislação & jurisprudência , Avaliação de Resultados da Assistência ao Paciente , Admissão e Escalonamento de Pessoal/legislação & jurisprudência , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Regulamentação Governamental , Humanos , Unidades de Terapia Intensiva/normas , Masculino , Massachusetts , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem no Hospital/normas , Admissão e Escalonamento de Pessoal/normas , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
13.
Ann Am Thorac Soc ; 15(8): 962-969, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29856657

RESUMO

RATIONALE: Immunosuppressive medical conditions are risk factors for mortality from severe infections. It is unknown whether hospital characteristics affect this risk. OBJECTIVES: To determine whether the odds of death for an immunosuppressed patient with sepsis relative to a nonimmunosuppressed patient with sepsis varies according to the hospital's yearly case volume of immunosuppressed patients with sepsis. METHODS: Patients with sepsis at hospitals in the Vizient database were characterized as immunosuppressed or not immunosuppressed on the basis of diagnosis codes and medication use. Hospitals were grouped into quartiles based on their average volumes of immunosuppressed patients with sepsis per year. Multilevel logistic regression with clustering of patients by hospital was used to determine whether the odds of in-hospital death from sepsis owing to a suppressed immune state varied by hospital quartile. RESULTS: There were 350,183 patients with sepsis at 60 hospitals in the Vizient database from 2010 to 2012. Immunosuppressed patients with sepsis at the 15 hospitals in the lowest quartile (64 to 224 immunosuppressed patients with sepsis per year) had an increased odds of in-hospital death relative to nonimmunosuppressed patients with sepsis at these hospitals (adjusted odds ratio, 1.38; 95% confidence interval, 1.27-1.50; P < 0.001). The odds of in-hospital death for immunosuppressed patients with sepsis relative to nonimmunosuppressed patients with sepsis was similar for patients at hospitals in the second, third, and fourth quartiles (225 to 1,056 immunosuppressed patients with sepsis per year). The adjusted odds of death from sepsis owing to a suppressed immune state of 1.21 (95% confidence interval, 1.18-1.25; P < 0.001) for patients at these 45 hospitals was significantly less than for patients at the 15 hospitals in the lowest quartile (P = 0.004 for difference). CONCLUSIONS: The risk of death from sepsis owing to a suppressed immune state was greatest at hospitals with the lowest volume of immunosuppressed patients with sepsis. Further study is needed to determine whether this finding is related to differences in patient characteristics or in care delivery at hospitals with different amounts of exposure to immunosuppressed patients.


Assuntos
Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Hospedeiro Imunocomprometido , Sepse/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Cuidados Críticos , Feminino , Hospitalização , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multinível , Razão de Chances , Sepse/imunologia
14.
J Am Geriatr Soc ; 66(7): 1377-1381, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29542117

RESUMO

OBJECTIVES: To inform the shared decision-making process between clinicians and older adults and their surrogates regarding emergency intubation. DESIGN: Retrospective cohort study. SETTING: Multicenter, emergency department (ED)-based cohort. PARTICIPANTS: Adults aged 65 and older intubated in the ED from 2008 to 2015 from 262 hospitals across the United States (>95% of U.S. nonprofit academic medical centers). MEASUREMENTS: Our primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds of death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographic region. RESULTS: We identified 41,463 ED intubation encounters and included 35,036 in the final analysis. Sixty-four percent were in non-Hispanic whites and 54% in women. Overall in-hospital mortality was 33% (95% confidence interval (CI)=34-35%). Twenty-four percent (95% CI=24-25%) of subjects were discharged to home, and 41% (95% CI=40-42%) were discharged to a location other than home. Mortality was 29% (95% CI=28-29%) for individuals aged 65 to 74, 34% (95% CI=33-35%) for those aged 75 to 79, 40% (95% CI=39-41%) for those aged 80 to 84, 43% (95% CI=41-44%) for those aged 85 to 89, and 50% (95% CI=48-51%) for those aged 90 and older. CONCLUSION: After emergency intubation, 33% percent of older adults die during the index hospitalization. Only 24% of survivors are discharged to home. Simple, graphic representations of this information, in combination with an experienced clinician's overall clinical assessment, will support shared decision-making regarding unplanned intubation.


Assuntos
Tomada de Decisões , Mortalidade Hospitalar/tendências , Intubação Intratraqueal/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências
15.
Transplantation ; 102(7): 1096-1107, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29557907

RESUMO

BACKGROUND: In the general population, even mild renal disease is associated with increased cardiovascular (CV) complications. Whether this is true in liver transplant recipients (LTR) is unknown. METHODS: This was a retrospective cohort study of 671 LTR (2002-2012) from a large urban tertiary care center and 37 322 LTR using Vizient hospitalization data linked to the United Network for Organ Sharing. The 4-variable Modification of Diet in Renal Disease equation estimated glomerular filtration rate (eGFR). Outcomes were 1-year CV complications (death/hospitalization from myocardial infarction, heart failure, atrial fibrillation, cardiac arrest, pulmonary embolism, or stroke) and mortality. Latent mixture modeling identified trajectories in eGFR in the first liver transplantation (LT) year in the 671 patients. RESULTS: Mean (SD) eGFR was 72.1 (45.7) mL/min per 1.73 m. Six distinct eGFR trajectories were identified in the local cohort (n = 671): qualitatively normal-slow decrease (4% of cohort), normal-rapid decrease (4%), mild-stable (18%), mild-slow decrease (35%), moderate-stable (30%), and severe-stable (9%). In multivariable analyses adjusted for confounders and baseline eGFR, the greatest odds of 1-year CV complications were in the normal-rapid decrease group (odds ratio, 10.6; 95% confidence interval, 3.0-36.9). Among the national cohort, each 5-unit lower eGFR at LT was associated with a 2% and 5% higher hazard of all-cause and CV-mortality, respectively (P < 0.0001), independent of multiple confounders. CONCLUSIONS: Even mild renal disease at the time of LT is a risk factor for posttransplant all-cause and CV mortality. More rapid declines in eGFR soon after LT correlate with risk of adverse CV outcomes, highlighting the need to study whether early renal preservation interventions also reduce CV complications.


Assuntos
Doenças Cardiovasculares/mortalidade , Doença Hepática Terminal/cirurgia , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Insuficiência Renal/fisiopatologia , Adulto , Idoso , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/fisiopatologia , Creatinina/sangue , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Insuficiência Renal/sangue , Insuficiência Renal/etiologia , Insuficiência Renal/mortalidade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo
16.
Infect Control Hosp Epidemiol ; 39(2): 229-232, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29331155

RESUMO

A metric was developed to identify hospital proportion of carbapenem consumption (PoCC) among antipseudomonal antibiotics. The PoCC varied significantly among academic medical centers by Census Bureau geographic division after adjusting for patient mix. This metric may be useful in identifying disproportionate carbapenem use and potential carbapenem overuse. Infect Control Hosp Epidemiol 2018;39:229-232.


Assuntos
Antibacterianos/uso terapêutico , Carbapenêmicos/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Infecções por Pseudomonas/tratamento farmacológico , Centros Médicos Acadêmicos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Censos , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pseudomonas/efeitos dos fármacos , Estados Unidos
17.
Circ Cardiovasc Qual Outcomes ; 11(11): e004466, 2018 11 14.
Artigo em Inglês | MEDLINE | ID: mdl-30785252

RESUMO

BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784­21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253­17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.


Assuntos
Implante de Prótese de Valva Cardíaca/economia , Custos Hospitalares , Anuloplastia da Valva Mitral/economia , Insuficiência da Valva Mitral/economia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Isquemia Miocárdica/complicações , Idoso , Simulação por Computador , Análise Custo-Benefício , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/mortalidade , Modelos Econômicos , Isquemia Miocárdica/mortalidade , Readmissão do Paciente/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
18.
Surg Endosc ; 32(6): 2886-2893, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29282576

RESUMO

BACKGROUND: Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties. METHODS: From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien-Dindo classification. RESULTS: We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2-< 3, 3-4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien-Dindo classification. CONCLUSIONS: The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.


Assuntos
Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Avaliação de Resultados da Assistência ao Paciente , Readmissão do Paciente/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Adulto Jovem
19.
J Hosp Med ; 12(12): 957-962, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29236093

RESUMO

BACKGROUND: Identifying hospitals that are both early and consistent adopters of high-value care can help shed light on the culture and practices at those institutions that are necessary to promote high-value care nationwide. The use of troponin to diagnose acute myocardial infarction (AMI), and not to test for myoglobin or creatine kinase-MB (CK-MB), is a high-value recommendation of the Choosing Wisely® campaign. OBJECTIVE: To examine the variation in cardiac biomarker testing and the effect of the Choosing Wisely® troponin-only recommendation for the diagnosis of AMI. DESIGN: A retrospective observational study using administrative ordering data from Vizient's Clinical Database/Resource Manager. SETTING: Ninety-one academic medical centers from the fourth quarter of 2013 through the third quarter of 2016. PATIENTS: Hospitalized patients with a principal discharge diagnosis of AMI. INTERVENTION: The Choosing Wisely® recommendation to order troponin-only testing to diagnose AMI was released during the first quarter of 2015. RESULTS: In 19 hospitals, troponin-only testing was consistently ordered to diagnose AMI before the Choosing Wisely® recommendation and throughout the study period. In 34 hospitals, both troponin and myoglobin/CK-MB were ordered to diagnose AMI even after the Choosing Wisely® recommendation. In 26 hospitals with low rates of troponin-only testing before the Choosing Wisely® recommendation, the release of the recommendation was associated with a statistically significant increase in the rate of troponin-only testing to diagnose AMI. CONCLUSIONS: In institutions with low rates of troponin-only testing prior to the Choosing Wisely® recommendation, the recommendation was associated with a significant increase in the rate of troponin-only testing.


Assuntos
Hospitais de Ensino/tendências , Infarto do Miocárdio/diagnóstico , Troponina/metabolismo , Biomarcadores/sangue , Biomarcadores/metabolismo , Fidelidade a Diretrizes , Hospitais de Ensino/estatística & dados numéricos , Humanos , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Fatores de Tempo , Troponina/sangue
20.
J Am Coll Surg ; 225(4): 532-537, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28754410

RESUMO

BACKGROUND: The laparoscopic adjustable gastric band (LAGB) was approved for use in the US in 2001 and has been found to be a safe and effective surgical treatment for morbid obesity. However, there is a recent trend toward reduced use of LAGB nationwide. The objective of this study was to examine the prevalence and outcomes of primary LAGB implantation compared with revision and explantation at academic centers. STUDY DESIGN: Data were obtained from the Vizient database from 2007 through 2015. The ICD-9-Clinical Modification and ICD-10-Clinical Modification were used to select patients with a primary diagnosis of obesity who had undergone LAGB implantation, revision, or explantation. Prevalence and outcomes of primary LAGB implantation compared with revision or explantation were analyzed. Outcomes measures included length of stay, ICU admission, morbidity, mortality, and cost. RESULTS: From 2007 through 2015, a total of 28,202 patients underwent LAGB implantation for surgical weight loss. The annual number of LAGB implantation procedures decreased steadily after 2010. In the same time period, 12,157 patients underwent LAGB explantation. In 2013, the number of LAGB explantation procedures exceeded that of implantation. Laparoscopic adjustable gastric band revision rates remained stable throughout the study period. Mean length of stay, serious morbidity, and proportion of patients requiring ICU admission were higher for gastric band revision and explantation cases compared with primary LAGB implantation cases. There was no statistically significant difference in mortality or mean cost between the 2 groups. CONCLUSIONS: Since 2013, the number of gastric band explantation procedures has exceeded that of implantation procedures at academic centers. Laparoscopic adjustable gastric band revision or explantation is associated with longer length of stay, higher rate of postoperative ICU admissions, and higher overall morbidity compared with LAGB implantation.


Assuntos
Remoção de Dispositivo , Gastroplastia/instrumentação , Hospitais de Ensino , Laparoscopia , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/cirurgia , Adolescente , Adulto , Feminino , Gastroplastia/efeitos adversos , Gastroplastia/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Reoperação , Resultado do Tratamento , Estados Unidos , Adulto Jovem
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