Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial.

OBJECTIVE: To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients. DESIGN: This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded. SETTING: Twenty-four-bed surgical ICU at a quaternary academic medical center. PATIENTS: Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included. INTERVENTIONS: Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309-0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5-16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95). CONCLUSIONS: Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type.

OBJECTIVE: To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative. METHODS: A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas. RESULTS: Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly ($68,050±184,541 vs. $19,498±31,506, P<0.001) versus community hospitals. CONCLUSIONS: Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.

Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis.

PURPOSE: The hypothesis that spondylolysis (SL) and/or isthmic spondylolisthesis (IS) cause low back pain (LBP) is widely accepted representing surgical indication in symptomatic cases. If SL/IS cause LBP, individuals with these conditions should be more prone to LBP than those without SL/IS. Therefore, the goal of the study was to assess whether the published primary data demonstrate an association between SL/IS and LBP in the general adult population. METHODS: Systematic review of published observational studies to identify any association between SL/IS and LBP in adults. The methodological quality of the cohort and case-control studies was evaluated using the Newcastle-Ottawa scale. RESULTS: Fifteen studies met inclusion criteria (one cohort, seven case-control, seven cross-sectional). Neither the cohort study nor the two highest-quality case-control studies detected an association between SL/IS and LBP; the same is true for the remaining studies. CONCLUSIONS: There is no strong or consistent association between SL/IS and LBP in epidemiological studies of the general adult population that would support a hypothesis of causation. It is possible that SL/IS coexist with LBP, and observed effects of surgery and other treatment modalities are primarily due to benign natural history and nonspecific treatment effects. We conclude that traditional surgical practice for the adult general population, in which SL/IS is assumed to be the cause of non-radicular LBP whenever the two coexist, should be reconsidered in light of epidemiological data accumulated in recent decades.

Reductions in Sepsis Mortality and Costs After Design and Implementation of a Nurse-Based Early Recognition and Response Program.

BACKGROUND: Sepsis is a leading cause of death, but evidence suggests that early recognition and prompt intervention can save lives. In 2005 Houston Methodist Hospital prioritized sepsis detection and management in its ICU. In late 2007, because of marginal effects on sepsis death rates, the focus shifted to designing a program that would be readily used by nurses and ensure early recognition of patients showing signs suspicious for sepsis, as well as the institution of prompt, evidence-based interventions to diagnose and treat it. METHODS: The intervention had four components: organizational commitment and data-based leadership; development and integration of an early sepsis screening tool into the electronic health record; creation of screening and response protocols; and education and training of nurses. Twice-daily screening of patients on targeted units was conducted by bedside nurses; nurse practitioners initiated definitive treatment as indicated. Evaluation focused on extent of implementation, trends in inpatient mortality, and, for Medicare beneficiaries, a before-after (2008-2011) comparison of outcomes and costs. A federal grant in 2012 enabled expansion of the program. RESULTS: By year 3 (2011) 33% of inpatients were screened (56,190 screens in 9,718 unique patients), up from 10% in year 1 (2009). Inpatient sepsis-associated death rates decreased from 29.7% in the preimplementation period (2006-2008) to 21.1% after implementation (2009-2014). Death rates and hospital costs for Medicare beneficiaries decreased from preimplementation levels without a compensatory increase in discharges to postacute care. CONCLUSION: This program has been associated with lower inpatient death rates and costs. Further testing of the robustness and exportability of the program is under way.

Comparative effectiveness of individual angiotensin receptor blockers on risk of mortality in patients with chronic heart failure.

OBJECTIVE: There is little evidence on comparative effectiveness of individual angiotensin receptor blockers (ARBs) in patients with chronic heart failure (CHF). This study compared four ARBs in reducing risk of mortality in clinical practice. METHODS: A retrospective analysis was conducted on a national sample of patients diagnosed with CHF from 1 October 1996 to 30 September 2002 identified from Veterans Affairs electronic medical records, with supplemental clinical data obtained from chart review. After excluding patients with exposure to ARBs within the previous 6 months, four treatment groups were defined based on initial use of candesartan, valsartan, losartan, and irbesartan between the index date (1 October 2000) and the study end date (30 September 2002). Time to death was measured concurrently during that period. A marginal structural model controlled for sociodemographic factors, comorbidities, comedications, disease severity (left ventricular ejection fraction), and potential time-varying confounding affected by previous treatment (hospitalization). Propensity scores derived from a multinomial logistic regression were used as inverse probability of treatment weights in a generalized estimating equation to estimate causal effects. RESULTS: Among the 1536 patients identified on ARB therapy, irbesartan was most frequently used (55.21%), followed by losartan (21.74%), candesartan (15.23%), and valsartan (7.81%). When compared with losartan, after adjusting for time-varying hospitalization in marginal structural model, candesartan (OR = 0.79, 95%CI = 0.42-1.50), irbesartan (OR = 1.17, 95%CI = 0.72-1.90), and valsartan (OR = 0.98, 95%CI = 0.45-2.14) were found to have similar effectiveness in reducing mortality in CHF patients. CONCLUSION: Effectiveness of ARBs in reducing mortality is similar in patients with CHF in everyday clinical practice.

A taxonomy of multinational ethical and methodological standards for clinical trials of therapeutic interventions.

BACKGROUND: If trials of therapeutic interventions are to serve society's interests, they must be of high methodological quality and must satisfy moral commitments to human subjects. The authors set out to develop a clinical-trials compendium in which standards for the ethical treatment of human subjects are integrated with standards for research methods. METHODS: The authors rank-ordered the world's nations and chose the 31 with >700 active trials as of 24 July 2008. Governmental and other authoritative entities of the 31 countries were searched, and 1004 English-language documents containing ethical and/or methodological standards for clinical trials were identified. The authors extracted standards from 144 of those: 50 designated as 'core', 39 addressing trials of invasive procedures and a 5% sample (N=55) of the remainder. As the integrating framework for the standards we developed a coherent taxonomy encompassing all elements of a trial's stages. FINDINGS: Review of the 144 documents yielded nearly 15 000 discrete standards. After duplicates were removed, 5903 substantive standards remained, distributed in the taxonomy as follows: initiation, 1401 standards, 8 divisions; design, 1869 standards, 16 divisions; conduct, 1473 standards, 8 divisions; analysing and reporting results, 997 standards, four divisions; and post-trial standards, 168 standards, 5 divisions. CONCLUSIONS: The overwhelming number of source documents and standards uncovered in this study was not anticipated beforehand and confirms the extraordinary complexity of the clinical trials enterprise. This taxonomy of multinational ethical and methodological standards may help trialists and overseers improve the quality of clinical trials, particularly given the globalisation of clinical research.

Hospital use and survival among Veterans Affairs beneficiaries.

BACKGROUND: Initiatives to reduce hospital care were part of the reorganization of the Department of Veterans Affairs (VA) medical care system undertaken in the mid-1990s. We examined changes in the use of VA health services and survival from 1994 through 1998 among VA beneficiaries with serious chronic diseases. We postulated that if access to hospital care was reduced too much, or if decreased hospital use was not offset by improvements in ambulatory care, urgent care visits would increase or survival rates would fall. METHODS: We tracked changes in risk-adjusted VA bed-day rates, rates of medical visits, rates of visits for testing and consultation, and rates of urgent care visits per patient-year among VA beneficiaries in nine disease cohorts (a total of 342,300 beneficiaries). Trends in non-VA hospital use by VA beneficiaries 65 years of age or older who were enrolled in fee-for-service Medicare were also studied. VA and Medicare vital-status data were used to calculate one-year survival rates. RESULTS: From 1994 through 1998, VA bed-day rates fell by 50 percent, rates of medical-clinic visits and visits for testing and consultation increased moderately, and rates of urgent care visits fell by 35 percent. The sharp decline in the use of VA hospitals was not compensated for by increases in the use of Medicare-reimbursed non-VA hospital care by veterans eligible for both VA care and Medicare, and the use of non-VA hospitals actually declined in four cohorts. The survival rates were essentially unchanged over the study period. CONCLUSIONS: The marked decline in VA hospital use from 1994 through 1998 did not curtail access to needed services and was not associated with serious consequences for chronically ill VA beneficiaries.

A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

BACKGROUND: Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. METHODS: A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic débridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated débridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial. RESULTS: At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and débridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and débridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. CONCLUSIONS: In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

Process of care and outcomes in patients with peripheral arterial disease.

BACKGROUND: We investigated the association of process of care measures with adverse limb and systemic events in patients with peripheral arterial disease (PAD). METHODS: We conducted a retrospective cohort study of patients with PAD, as defined by an ankle-brachial index (ABI) <0.9. The index date was defined as the date, during 1995 to 1998, when the patient was seen in the Michael E. DeBakey VA Medical Center noninvasive vascular laboratory and found to have PAD. We conducted a chart review for process of care variables starting 3 years before the index date and ending at the time of the first event or the final visit (December 31, 2001), whichever occurred first. We examined the association between PAD process of care measures, including risk factor control, and prescribing of medication, with time of the patient's first major limb event or death. RESULTS: Of the 796 patients (mean age, 65 +/- 9.9 years), 230 (28.9% experienced an adverse limb event (136 lower-extremity bypass, 94 lower-extremity amputation), and 354 (44.5%) died. Of the patients who died, 247 died without a preceding limb event. Glucose control was protective against death or a limb event with a hazard ratio (HR) of 0.74 (95% confidence limits [CL] 0.60, 0.91, P = 0.004). African Americans were at 2.8 (95% CL 1.7, 4.5) times the risk of Whites or Hispanics for an adverse limb event. However, this risk was no longer significant if their glucose was controlled. For process measures, the dispensing of PAD specific medication (HR 1.4, 95% CL 1.1, 1.7) was associated an increased risk for an adverse outcome. CONCLUSIONS: Our data suggest that glucose control is key to reducing the risk for adverse outcomes, particularly limb events in African Americans. Certain process of care measures, as markers of disease severity and disease management, are associated with poor outcomes in patients with PAD. Further work is needed to determine the role of early disease intervention to reduce poor outcomes in patients with PAD.

Open versus endovascular abdominal aortic aneurysm repair in VA hospitals.

BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR), when compared with conventional open surgical repair, has been shown to reduce perioperative morbidity and mortality. We performed a retrospective cohort study with prospectively collected data from the Department of Veterans Affairs to examine outcomes after elective aneurysm repair. STUDY DESIGN: We studied 30-day mortality, 1-year survival, and postoperative complications in 1,904 patients who underwent elective abdominal aortic aneurysm repair (EVAR n=717 [37.7%]; open n=1,187 [62.3%]) at 123 Department of Veterans Affairs hospitals between May 1, 2001 and September 30, 2003. We investigated the influence of patient, operative, and hospital variables on outcomes. RESULTS: Patients undergoing EVAR had significantly lower 30-day (3.1% versus 5.6%, p=0.01) and 1- year mortality rates (8.7% versus 12.1%, p=0.018) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio[OR]=0.59; 95% CI=0.36, 0.99; p=0.04). The risk of perioperative complications was much less after EVAR (15.5% versus 27.7%; p<0.001; unadjusted OR 0.48; 95% CI=0.38, 0.61; p<0.001). Patients operated on at low volume hospitals (25% of entire cohort) were more likely to have had open repair (31.3% compared with 15.9% EVAR; p<0.001) and a nearly two-fold increase in adjusted 30-day mortality risk (OR=1.9; 95% CI=1.19, 2.98; p=0.006). CONCLUSIONS: In routine daily practice, veterans who undergo elective EVAR have substantially lower perioperative mortality and morbidity rates compared with patients having open repair. The benefits of a minimally invasive approach were readily apparent in this cohort, but we recommend using caution in choosing EVAR for all elective abdominal aortic aneurysm repairs until longer-term data on device durability are available.

Surgeon-Specific Reports in General Surgery: Establishing Benchmarks for Peer Comparison Within a Single Hospital.

BACKGROUND: Methods to assess a surgeon's individual performance based on clinically meaningful outcomes have not been fully developed, due to small numbers of adverse outcomes and wide variation in case volumes. The Achievable Benchmark of Care (ABC) method addresses these issues by identifying benchmark-setting surgeons with high levels of performance and greater case volumes. This method was used to help surgeons compare their surgical practice to that of their peers by using merged National Surgical Quality Improvement Program (NSQIP) and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data to generate surgeon-specific reports. STUDY DESIGN: A retrospective cohort study at a single institution's department of surgery was conducted involving 107 surgeons (8,660 cases) over 5.5 years. Stratification of more than 32,000 CPT codes into 16 CPT clusters served as the risk adjustment. Thirty-day outcomes of interest included surgical site infection (SSI), acute kidney injury (AKI), and mortality. Performance characteristics of the ABC method were explored by examining how many surgeons were identified as benchmark-setters in view of volume and outcome rates within CPT clusters. RESULTS: For the data captured, most surgeons performed cases spanning a median of 5 CPT clusters (range 1 to 15 clusters), with a median of 26 cases (range 1 to 776 cases) and a median of 2.8 years (range 0 to 5.5 years). The highest volume surgeon for that CPT cluster set the benchmark for 6 of 16 CPT clusters for SSIs, 8 of 16 CPT clusters for AKIs, and 9 of 16 CPT clusters for mortality. CONCLUSIONS: The ABC method appears to be a sound and useful approach to identifying benchmark-setting surgeons within a single institution. Such surgeons may be able to help their peers improve their performance.

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT.

UNLABELLED: The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP). METHODS: This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome. RESULTS: Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P < 0.0001). CONCLUSION: Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

Impact of race on health care utilization and outcomes in veterans with congestive heart failure.

OBJECTIVES: The objectives of this study were to determine racial differences in mortality in a national cohort of patients hospitalized with congestive heart failure (CHF) within a financially "equal-access" healthcare system, the Veterans Health Administration (VA), and to examine racial differences in patterns of healthcare utilization following hospitalization. BACKGROUND: To explain the observed paradox of increased readmissions and lower mortality in black patients hospitalized with CHF, it has been postulated that black patients may have reduced access to outpatient care, resulting in a higher number of hospital admissions for lesser disease severity. METHODS: In a retrospective study of 4,901 black and 17,093 white veterans hospitalized with CHF in 153 VA hospitals, we evaluated mortality at 30 days and 2 years, and healthcare utilization in the year following discharge. RESULTS: The risk-adjusted odds ratios (OR) for 30-day and 2-year mortality in black versus white patients were 0.70 (95% confidence interval [CI] 0.60 to 0.82) and 0.84 (95% CI 0.78 to 0.91), respectively. In the year following discharge, blacks had the same rate of readmissions as whites. Blacks had a lower rate of medical outpatient clinic visits and a higher rate of urgent care/emergency room visits than whites, although these differences were small. CONCLUSIONS: In a system where there is equal access to healthcare, the racial gap in patterns of healthcare utilization is small. The observation of better survival in black patients after a CHF hospitalization is not readily explained by differences in healthcare utilization.

Ethnicity and peripheral arterial disease.

OBJECTIVE: To determine whether race/ethnicity is an independent risk factor for peripheral arterial disease (PAD). PATIENTS AND METHODS: From September 2000 through August 2001, we screened patients (age > or = 55 years) for PAD within 4 primary care clinics located in the Houston, Tex, area. Variables that were bivariately associated with PAD (P< or = .05) were selected for entry into a multivariate logistic regression model to determine the independent risk factors for PAD. RESULTS: Among 403 patients (136 white, 136 African American, and 131 Latino patients, 81 of whom were Spanish speaking), the prevalence of PAD was 22.8% among African American patients, 13.7% among Latino patients, and 13.2% among white patients (P = .06). Within the multivariate model, adjusting for age, smoking status (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.27-5.25), diabetes mellitus (OR, 2.98; 95% CI, 1.58-5.63), hypertension (OR, 2.58; 95% CI, 1.12-5.95), and education, African American and Latino patients were not more likely than white patients to have a diagnosis of PAD (OR 1.89, 95% CI 0.89-3.99 and OR 1.54, 95% CI 0.59-4.06, respectively). CONCLUSION: After adjusting for atherosclerotic risk factors and level of education, ethnicity was not an independent risk factor for PAD. When determining ethnic variation in outcomes among patients with PAD, efforts are needed to better understand the role of the primary care setting to reduce the burden of social inequality on health.

Measurement in Veterans Affairs Health Services Research: veterans as a special population.

OBJECTIVE: To introduce this supplemental issue on measurement within health services research by using the population of U.S. veterans as an illustrative example of population and system influences on measurement quality. PRINCIPAL FINDINGS: Measurement quality may be affected by differences in demographic characteristics, illness burden, psychological health, cultural identity, or health care setting. The U.S. veteran population and the VA health system represent a microcosm in which a broad range of measurement issues can be assessed. CONCLUSIONS: Measurement is the foundation on which health decisions are made. Poor measurement quality can affect both the quality of health care decisions and decisions about health care policy. The accompanying articles in this issue highlight a subset of measurement issues that have applicability to the broad community of health services research. It is our hope that they stimulate a broad discussion of the measurement challenges posed by conducting "state-of-the-art" health services research.

Measuring diagnoses: ICD code accuracy.

OBJECTIVE: To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process. DATA SOURCES/STUDY SETTING: The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications. STUDY DESIGN/METHODS: We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy. PRINCIPLE FINDINGS: Main error sources along the "patient trajectory" include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the "paper trail" include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding. CONCLUSIONS: By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways.

Treatable comorbid conditions and use of VA health care services among patients with dementia.

OBJECTIVE: Although dementia is a progressive degenerative disease, treatable comorbid symptoms, such as pain, aggression, depression, and psychosis, occur among more than 60 percent of patients with dementia. Compared with age-matched controls, patients with dementia use 70 percent more health services and account for 50 percent more managed care costs. This prospective study examined the longitudinal relationship between use of health care services and treatable comorbid conditions among patients with dementia. METHODS: Ninety-nine patient-caregiver dyads from the Michael E. DeBakey Veterans Affairs (VA) Medical Center in Houston, Texas, completed a one-time interview. Patients' VA records were reviewed one year later to examine the relationships between the study variables and three types of service use: inpatient medical stays, outpatient medical visits, and outpatient psychiatric visits. RESULTS: Pain was positively associated with all types of service use. Depression was associated with outpatient psychiatric visits. Psychosis and aggression were not significantly associated with future use of health care services. CONCLUSIONS: The results of this study confirm previous findings that pain and depression are associated with increased use of health care services. Although the other treatable comorbid symptoms, with the exception of pain, are associated with increased service use, their impact varies depending on the type of services provided. Interventions to improve the assessment and treatment of comorbid symptoms, especially pain, among patients with dementia may reduce service needs and thus reduce medical care costs.

Strategic opportunities in the oversight of the U.S. hospital accreditation system.

Hospital accreditation and state certification are the means that the Centers for Medicare & Medicaid Services (CMS) employs to meet quality of care requirements for medical care reimbursement. Hospitals can choose to use either a national accrediting agency or a state certification inspection in order to receive Medicare payments. Approximately, 80% of hospitals choose the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The purpose of this paper is to analyze and discuss improvements on the structure of the accreditation process in a Principal-Agent-Supervisor framework with a special emphasis on the oversight by the principal (CMS) of the supervisor (JCAHO).

The prevalence of peripheral arterial disease in a racially diverse population.

BACKGROUND: The purpose of this study was to determine the prevalence of peripheral arterial disease (PAD) in white, African American, and English- and Spanish-speaking Hispanic patients. METHODS: We screened patients older than 50 years for PAD at 4 primary care clinics located in the Houston Veterans Affairs Medical Center and the Harris County Hospital District. The disease was diagnosed by an ankle-brachial index of less than 0.9. Patients also completed questionnaires to ascertain symptoms of intermittent claudication, walking difficulty, medical history, and quality of life. RESULTS: We enrolled 403 patients (136 whites; 136 African Americans; and 131 Hispanics, 81 of whom were Spanish speaking). The prevalence of PAD was 13.2% among whites, 22.8% among African Americans, and 13.7% among Hispanics (P =.06). African Americans had a significantly higher prevalence of PAD than whites and Hispanics combined (P =.02). Among all patients who were diagnosed as having PAD on the basis of their ankle-brachial index, only 5 (7.5%) had symptoms of intermittent claudication. CONCLUSIONS: Peripheral arterial disease is a prevalent illness in the primary care setting. Its prevalence varies by race and is higher in African Americans than in whites and Hispanics. Relative to the prevalence of PAD, the prevalence of intermittent claudication is low. Since measurement of the ankle-brachial index is not part of the routine clinic visit, many patients with PAD are not diagnosed unless they develop symptoms of intermittent claudication. Because of this, it is likely that many patients remain undiagnosed. Efforts are needed to improve PAD detection in the primary care setting.