Letter to editor: is laboratory index really a practical and valid tool to predict mortality?

We carefully studied the article titled "A practical laboratory index to predict institutionalization and mortality - an 18-year population-based follow-up study" written by Heikkilä et al. and published in BMC Geriatrics on 25 February 2021 with great interest. We would like to make some comments regarding this article and tool. Laboratory Index (LI) has been executed with the data of 728 patients who had followed-up in our center, however the LI score was not able to predict the 10-year and 18-year mortality. Therefore, a question mark has been aroused in our minds at some points. Neither frailty nor comorbidities were considered in this index. For a geriatric patient, it would be inadequate to evaluate laboratory results regardless of the clinical status. Similarly, it would not be appropriate to predict mortality only on the basis of laboratory results without considering the clinical status of the patient.We think that although the recent study has a great impact, it can be improved by incorporating data on the comorbidities and frailty status of the patients into the analysis.

Mortality index is more accurate than volume in predicting outcome and failure to rescue in Medicare beneficiaries undergoing robotic right upper lobectomy.

Background: Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand and there is variability in outcomes among hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic right upper lobectomy (RRUL). Methods: Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients age ≥65 years with a diagnosis of lung cancer who underwent RRUL between January 2018 and December 2020. We excluded patients who had undergone segmentectomy, sublobar, wedge, or bronchoplastic resection; had metastatic or nonmalignant disease; or had a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open surgery, complications, and costs. We analyzed hospitals by tertiles of volume and Medicare Mortality Index (MMI). Defined as the institutional number of deaths per number of survivors, MMI is a marker of overall hospital performance and quality. Propensity score models were adjusted for confounding using goodness of fit. Results: Data for 4317 patients who underwent robotic right upper lobectomy were analyzed. Hospitals were categorized by volume of cases (low, <9; medium, 9-20; high, >20) and MMI (low, <0.04; medium, 0.04-0.13; high, >0.13). After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs $30,316; P = .006), as well as higher mortality (odds ratio, 7.46; 95% confidence interval, 2.67-28.2; P < .001). Compared to high-volume centers, low-volume centers had higher rates of conversion to open surgery, respiratory failure, hemorrhagic anemia, and death; longer LOS; and greater cost (P < .001 for all). The C-statistic for volume as a predictor of overall mortality was 0.6, and the FTR was 0.8. Hospitals in the highest tertile of MMI had the highest rates of conversion to open surgery (P = .01), pneumothorax (P = .02), and respiratory failure (P < .001). They also had the highest mortality and rate of readmission, longest LOS, and greatest costs (P < .001 for all) and the shortest survival (P < .001). The C-statistic for MMI as a predictor of overall mortality was 0.8, and FTR was 0.9. Conclusions: The MMI incorporates hospital-based factors in the adjudication of outcomes and is a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost-effectiveness measures in hospitals seeking to implement robotic lung surgery programs.

A study of grief experience interviews with family members of patients with advanced malignant tumors based on noninvasive death index monitoring.

OBJECTIVE: To explore the grief experiences of family members of patients with advanced malignant tumors before and after death. METHODS: This study used both quantitative and qualitative research methods. A total of 10 people with family members with terminal malignant tumors were chosen and assessed five times according to a specific non-invasive mortality index and the Distress Thermometer scale. Additionally, the participants attended an in-depth interview. RESULTS: The grief experiences of the bereaved included their knowledge of and attitude towards death, the physical and mental conditions of the family members of patients in the terminal stage, the needs of family members, and the response to death and growth of those family members. CONCLUSIONS: The grief experience interviews of family members of patients with advanced malignant tumors are universal. It is suggested that the nursing staff should pay attention to the emotional experience of the bereaved after the death of the patient throughout the whole nursing process, including the continuous follow-up during the home period. It is hoped that the implementation of grief counseling methods in the later stage can help the bereaved to successfully go through the grieving period, prevent grief disorders, and help them return to society.

Maternal Near-Miss and Maternal Mortality in a Tertiary Care Center of Western Uttar Pradesh: A Retrospective Study.

INTRODUCTION: Maternal mortality is an important indicator to assess the quality of services provided by the health care system. However, maternal near-misses as well as maternal mortality are also indicators of how well the health care system serves pregnant women. To improve our healthcare system in terms of investigative capacity, infrastructure, and personnel, a near-miss registry can provide important information on gaps in pregnancy facilities. This will help us to identify the requirements for referral facility improvements and the need for various health awareness programs. We, therefore, designed this study to analyze the various near-miss events in mothers and compare them with maternal mortality. METHODS: Present study was conducted in the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial (L.L.R.M.) Medical College associated with Sardar Vallabh Bhai Patel (S.V.B.P.) Hospital Meerut, Uttar Pradesh (UP), India for a period of one year and data were collected retrospectively from January 2022 to January 2023. All patients with life-threatening conditions such as excessive bleeding during pregnancy, hypertensive disorders of pregnancy (HDP), and septicemia that occurred during pregnancy or childbirth or within 42 days of termination of pregnancy and required ICU admissions, were included in the study. The total number of deliveries during the study period was 4,360 with 4,333 live births (LB). The total number of eligible cases was 79, out of which 52 were identified as maternal near misses and 27 were maternal mortality. Various maternal mortality and near-miss indices were analysed and statistical analysis was done using the SPSS version 21 (IBM Corp., Armonk, NY, USA). RESULTS: Our hospital's maternal mortality ratio (MMR) was 623/1lakh (0.623%), which is higher than the probability due to the deficiency of appropriate medical services in the nearby areas of western UP. The number of maternal near misses per 1000 LB (maternal near-miss ratio [MNMR]) was 12/1000 LB and the severe maternal outcome rate (SMOR) was 18/1000 LB (1.82%). In our study, hemorrhage and hypertensive disorder in pregnancy were the leading cause of morbidity and mortality followed by sepsis and severe anemia. Among organ dysfunction cardiac illness followed by respiratory dysfunction was the leading cause of morbidity and mortality. CONCLUSION: It is clear that there is a high burden of maternal near-miss in developing countries. There should be the establishment of well-equipped referral units at the periphery with trained manpower. The establishment of obstetrical high-dependence units (HDUs), rapid availability of blood and blood products, training of staff, and availability of multidisciplinary teams can minimize maternal mortality and morbidity.

Correlation Between Mask Compliance and COVID-19 Outcomes in Europe.

Masking was the single most common non-pharmaceutical intervention in the course of the coronavirus disease 2019 (COVID-19) pandemic. Most countries have implemented recommendations or mandates regarding the use of masks in public spaces. The aim of this short study was to analyse the correlation between mask usage against morbidity and mortality rates in the 2020-2021 winter in Europe. Data from 35 European countries on morbidity, mortality, and mask usage during a six-month period were analysed and crossed. Mask usage was more homogeneous in Eastern Europe than in Western European countries. Spearman's correlation coefficients between mask usage and COVID-19 outcomes were either null or positive, depending on the subgroup of countries and type of outcome (cases or deaths). Positive correlations were stronger in Western than in Eastern European countries. These findings indicate that countries with high levels of mask compliance did not perform better than those with low mask usage.

Maternal near-miss and mortality in a teaching hospital in Tigray region, Northern Ethiopia.

OBJECTIVE: This study seeks to examine the prevalence of maternal morbidities and deaths in Ayder Comprehensive Specialized Hospital from 1 July 2018 to 30 June 2019. METHODS: This was a cross-sectional study. Total purposive sampling method was employed to collect data prospectively using modified World Health Organization criteria for baseline assessment of maternal near-miss and mortality. Pregnant women or those who are within 42 days postpartum/any form of pregnancy termination that satisfy the inclusion criteria were enrolled. RESULTS: A total of 691 mothers were recorded as having severe maternal complications. Out of these, 170 women developed severe maternal outcome, ending with 146 maternal near-miss cases and 24 maternal deaths. The maternal near-miss ratio and maternal mortality ratio were 28.5 per 1000 live births and 469.1 per 100,000 live births, respectively. The overall mortality index was 14%. The top underlying causes of severe maternal complications were the infamous triads of preeclampsia (n = 303, 43.8%), obstetric hemorrhage (n = 166, 24.0%) and sepsis (n = 130, 18.8%). About 62.5% of mothers who died were not admitted to intensive care unit. CONCLUSION: This study found that the infamous triads of preeclampsia, obstetric hemorrhage and sepsis persist as the commonest causes of severe maternal complications in the study area. A significant number of women with severe maternal outcome were not admitted to intensive care unit. It also highlights that the severe maternal complications, severe maternal outcome, maternal near-miss ratio and mortality index in the study area are disproportionately higher than the global average. These staggering numbers call for a system re-thinking at multiple junctures.

Socioeconomic Determinants of COVID-19 Incidence and Mortality in Florida.

A wide variety of social determinants of health have been associated with various risks and impacts on quality of life. Specifically, poverty, lack of insurance coverage, large household sizes, and social vulnerability are all factors implicated in incidence and mortality rates of infectious disease. However, no studies have examined the relationship of these factors to the COVID-19 pandemic on a state-wide level in Florida. Thereby, the objective of this study is to examine the relationship between average household size, poverty, uninsured populations, social vulnerability index (SVI), and rates of COVID-19 cases and deaths in Florida counties. The objective was accomplished by analyzing the cumulative case and death reports from state and local health departments in Florida. The data was compiled into a single dataset by the CDC COVID-19 Task Force. Using US Census Bureau data, all Florida counties were classified into tertiles of the separate categories of poverty rate, average household size, uninsured rates, and SVI (Social Vulnerability Index). The poverty level was classified as low (0-12.3%), moderate (12.3-17.3%), and high (>17.3% below the federal poverty line). The uninsured population proportion was classified as low (0-7.1%), moderate (7.1-11.4%), and high (>11.4% uninsured residents). Average county household size was classified as low (0-2.4), moderate (2.4-2.6), and high (>2.6). The Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI) used US census data on 15 social determinants of vulnerability to evaluate and assist disadvantaged communities. SVI tertiles were low (0-0.333), moderate (0.334-0.666), and high (0.667-1) on a range of 0-1, with higher numbers signifying communities with many factors of social vulnerability. The mean cumulative cases and deaths per 100,000 inhabitants were calculated in each tertile for each category. Analysis of the data revealed that case and mortality rates due to COVID-19 in the high poverty counties were markedly higher in Florida than the national average. In contrast, moderate and low poverty rates were below average. Similarly, counties with a high SVI had case and mortality rates greatly above state and national averages. Counties with a high proportion of uninsured displayed the highest case rates. However, mortality rates were the highest in counties with a low proportion of uninsured individuals. No clear correlation was observed between COVID-19 rates and household size. It was concluded that compiled CDC and US census data suggests a significant correlation between poverty, social vulnerability, lack of insurance coverage, and increased incidence and mortality from COVID-19. Future research should statistically analyze the correlations and examine the individual factors of SVI as potential COVID-19 predictors.

Maternal near-miss patients and maternal mortality cases in a Turkish tertiary referral hospital.

OBJECTIVES: This study aimed to estimate the incidence of maternal near-miss (MNM) morbidity in a tertiary hospital setting in Turkey. MATERIAL AND METHODS: In this retrospective study, we concluded 125 MNM patients who delivered between January 2017 and December 2017 and fulfilled the WHO management-based criteria and severe pre-eclamptic and HELLP patients which is the top three highest mortality rates due to pregnancy. Two maternal death cases were also included. The indicators to monitor the quality of obstetric care using MNM patients and maternal deaths were calculated. Demographic characteristics of the patients, the primary diagnoses causing MNM and maternal deaths, clinical and surgical interventions in MNM patients, shock index (SI) value of the patients with obstetric hemorrhage and maternal death cases were evaluated. RESULTS: The MNM ratio was 5.06 patients per 1000 live births. Maternal mortality (MM) ratio was 8.1 maternal deaths per 100 000 live births. SMOR was 5.14 per 1000 live births. The MI was 1.57%, and the MNM/maternal death ratio was 62.4:1. The SI of MNM patients with obstetric hemorrhage was 1.36 ± 0.43, and the SI of the patient who died due to PPH was 1.74. CONCLUSION: The MNM rates and MM rates in our hospital were higher than high-income countries but were lower than in low- and middle-income countries. Hypertensive disorders and obstetric hemorrhage were the leading conditions related to MNM and MM. However, the MIs for these causes were low, reflecting the good quality of maternal care and well-resourced units. Adopting the MNM concept into the health system and use as an indicator for evaluating maternal health facilities is crucial to prevent MM.

Maternal Near Miss: Unraveling Our Experience in the Tertiary Care Hospital of Andaman and Nicobar Islands.

CONTEXT: Women who survive life-threatening complications related to pregnancy and delivery have many common aspects with those who die of such complications. This similarity brought forward the near miss concept in maternal health. Analysis of the similarities, differences, and the relationship between these two groups of women provide a complete assessment of quality of maternal health care. AIMS: The aim of this study is to assess the baseline indices of maternal near miss (MNM) and analyze the quality of care at a tertiary care center in Andaman and Nicobar Islands. SETTINGS AND DESIGN: Facility-based, cross-sectional study. SUBJECTS AND METHODS: The study was conducted for a period of 18 months from January 1, 2015, to August 31, 2016. Cases, who met the World Health Organization (WHO) criteria of severe obstetric morbidity, were included and followed up during their hospital stay and till their discharge or death. Quality of maternal health care was assessed through the WHO near-miss criteria and criterion-based clinical audit methodology. STATISTICAL ANALYSIS USED: Descriptive statistics using mean and percentages and Student's t-test were used. RESULTS: Among 4720 women who delivered in our hospital, there were 4677 live births, 52 patients were near miss, and there were 9 maternal deaths. The MNM incidence ratio was 11.11%, the MNM mortality ratio was 5.77, and the mortality index 14.75%. The most common cause of maternal morbidity was hemorrhage followed by hypertensive disorders. CONCLUSIONS: Improving referral systems, effective use of critical care, and evidence-based interventions can potentially reduce severe maternal outcomes.

A Revised Comorbidity Model for Administrative Databases Using Clinical Classifications Software Refined Variables.

Background and objective Database research has shaped policies, identified trends, and informed healthcare guidelines for numerous disease conditions. However, despite their abundant uses and vast potential, administrative databases have several limitations. Adjusting outcomes for comorbidities is often needed during database analysis as a means of overcoming non-randomization. We sought to obtain a model for comorbidity adjustment based on Clinical Classifications Software Refined (CCSR) variables and compare this with current models. Our aim was to provide a simplified, adaptable, and accurate measure for comorbidities in the Agency for Healthcare Research and Quality (AHRQ) databases, in order to strengthen the validity of outcomes.  Methods The Nationwide Inpatient Sample (NIS) database for 2018 was the data source. We obtained the mortality rate among all included hospitalizations in the dataset. A model based on CCSR categories was mapped from disease groups in Sundararajan's adaptation of the modified Deyo's Charlson Comorbidity Index (CCI). We employed logistic regression analysis to obtain the final model using CCSR variables as binary variables. We tested the final model on the 10 most common reasons for hospitalizations. Results The model had a higher area under the curve (AUC) compared to the three modalities of the CCI studied in all the categories. Also, the model had a higher AUC compared to the Elixhauser model in 8/10 categories. However, the model did not have a higher AUC compared to a model made from stepwise backward regression analysis of the original 21-variable model. Conclusion We developed a 15-CCSR-variable model that showed good discrimination for inpatient mortality compared to prior models.

A Review of Maternal Near Miss Cases in Selected Hospitals in North-East India.

BACKGROUND: The major causes of maternal near miss (MNM) and maternal death (MD) are similar, so review of MNM cases is likely to yield valuable information regarding severe morbidity, which, if untreated may lead to maternal mortality. OBJECTIVES: The objective is to determine frequency of near miss cases and identify the risk factors associated with MNM. MATERIALS AND METHODS: A cross-sectional study was done from June 2015 to October 2017 in three hospitals in Manipur and Nagaland. All cases of MNM, which occurred during this period, were included and were reviewed using their records. Family members and health care providers of 9 recent cases were interviewed. Data collected were coded and relevant themes were identified. RESULTS: There were 32,110 deliveries, 147 near miss cases and 12 MDs, resulting in maternal mortality ratio of 38/100,000 live birth (LB), severe maternal outcome ratio of 5/1000 LB and MNM ratio of 4.6/1000 LB. MNM to mortality ratio was 12.2:1 and mortality index was 7.5%. 83% of the cases of MNM were pregnancy related while 15.6% were related to preexisting disorders. The three delays remain the decisive factors in maternal mortality. CONCLUSION: Most of the near miss cases experienced delay in decision to seek health care, which resulted from underestimating the severity of various pregnancy-related conditions. Poor knowledge of the risk of warning signs of pregnancy plays a major part in the delay of management.

Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality.

STUDY OBJECTIVE: Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DESIGN: Time Series of prospectively recorded and historical data. SETTING: Academic tertiary care medical center and health system. PATIENTS: 449 patients undergoing elective primary hip surgery. INTERVENTIONS: For the intervention group we redesigned care with a comprehensive 14-16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MEASUREMENTS: The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. MAIN RESULTS: Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). CONCLUSIONS: A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

Reducing the Reported Mortality Index Within a Neurocritical Care Unit Through Documentation and Coding Accuracy.

BACKGROUND: The mortality index, or the ratio of observed to expected mortality, is a reported quality metric that has been assumed to directly reflect patient care. However, documentation and coding that does not use knowledge of how a reported mortality index is derived could reflect poorly on a hospital or service line. We present our effort at reducing the reported mortality index of neurosurgery and neurology patients within a neurocritical care unit through documentation and coding accuracy with direct incorporation of mortality modeling. METHODS: Using a reported method from Vizient Inc., we generated a spreadsheet tool to enable direct manipulation of the data to identify documentation and coding issues that influenced the reported mortality index in a retrospective set of patients. Subsequently, we implemented the prospective changes to documentation and coding and compared our calculated mortality index to the reported Vizient mortality index. RESULTS: Prospective implementation of the documentation and coding issues identified through our spreadsheet tool resulted in a drastic reduction of both our calculated and the reported Vizient mortality index. CONCLUSIONS: Incorporating knowledge of mortality index modeling into the documentation and coding resulted in impressive reductions in the reported mortality index for our patients, serving as a both an internal benchmark and a method of comparison with other institutions.

Incidence-Proportion of Maternal Near-Misses and Associated Factors in Southwest Ethiopia: A Prospective Cross-Sectional Study.

BACKGROUND: Pregnancy-related morbidity and mortality continue to have a serious impact on the lives of women all over the world. Women in sub-Saharan Africa accounted for nearly two-thirds of global maternal deaths. The World Health Organization recommends monitoring maternal near-miss provides better information regarding the quality of maternal health care, on which to base action to prevent further death. Accordingly, this study sought to assess the incidence-proportion of maternal near-miss and its risk factors. We have also seen the near-miss-to-mortality ratio and overall maternal mortality index. METHODS: An institution-based prospective cross-sectional study was carried out from February 6, 2017 to March 6, 2017, using the WHO criteria for maternal near-misses at the three randomly selected public hospitals. About 845 participants were enrolled in the study with systematic random sampling techniques. WHO multi-country survey on maternal and neonatal health tool was used. Descriptive statistics and bivariate logistic regression analysis were done. Variables with p-value <0.2 in the bivariate analysis were transferred to multivariable analysis, and during multivariate logistic regression analysis, variables with P-value <0.05 were considered as statistically significant with 95% CI. RESULTS: There were 5530 live births, 210 maternal near-misses, 17 maternal deaths, and 364 maternal near-miss events. The overall proportion of maternal near-miss is 24.85%. Besides, the ratio of maternal near-misses to maternal mortality was 12.35:1, and the overall mortality index was 7.48%. Parity, residence, a distance of maternal home from the hospital, ANC follow-up, duration of labor, and administration-related problems were found to have statistically significant associations. CONCLUSION: The incidence-proportion of maternal near-misses is relatively high when compared against the national target and to other regional studies. Besides, with all its limitations, the outcome indicators and outcome measures in this study seem to suggest optimum care is being given to mothers who suffered from life-threatening complications.

Impact of adverse drug reactions on the coding of a hospital stay in Quebec: exploratory descriptive study by simulation.

The discharge summary sheet's coding allows calculation of the severity index (SI), mortality index (MI), and resource intensity weight (RIW). These indicators help to describe the burden of care for individual cases and could potentially influence patient-based funding. This study was undertaken to simulate the impact of different adverse drug reactions (ADRs) on the hospital length of stay, thus allowing calculation of the effect of ADRs on the SI, MI, and RIW. This exploratory descriptive study was based on computer simulations. We created, by simulation, seven patient profiles of various complexities representative of our patients. Fifteen types of combination of drug and ADR manifestation comprising 15 ADR caused by eight different drug classes were identified based on the most frequently coded ADR in fiscal years 2016-2017 and 2017-2018. Those 15 combinations were applied to the patient profile to simulate the impact on the SI, MI, and RIW in eight scenarios. From these data, we measured the impact of the ADRs on these indicators. A total of 1,571 simulations were run. In general, the addition of a couple of drug and ADR manifestation contributed to increases in all three of the indicators. More specifically, the SI and RIW both increased in 30.7% (n = 482), whereas the MI increased in 14.6% (n = 229). For a same scenario, the impact on the three indicators could vary depending on the patient profile to which it was applied. This study has presented simulation data on the impact of the coding of ADRs on the hospital stay of a patient in Quebec.

"Near-Miss" Obstetric Events and Maternal Deaths in a Rural Tertiary Care Center in North India.

Introduction Maternal near-miss and maternal mortality cases have common characters, especially in terms of risk factors. Both of them are indicators of the quality of health care services provided to pregnant women. Our center is a tertiary care center in a rural area of western Uttar Pradesh (U.P.) so we get a large number of referred cases from most of the rural areas of western U.P. and the adjoining areas of other states too, which sometimes end up in mortality. Thus this study was planned to find out the incidence of maternal near-miss events and compare the nature of near-miss events with maternal mortality. Goal and objectives The main objectives of the study were to determine the frequency of maternal near-miss events, observe the trend of near-miss events, and compare the nature of near-miss events with maternal mortality. Materials and methods It was a retrospective study conducted in the department of obstetrics and gynecology at Uttar Pradesh University of Medical Sciences (UPUMS), Saifai, Etawah, from July 2018 - June 2019, over a period of one year. Potentially life-threatening conditions and maternal mortalities were noted from the records of the hospital after taking ethical clearance from the institute. Near-miss cases were noted based on the Health and Family Welfare Government of India guidelines 2014. Data were collected and statistical analysis was performed using the Statistical Package of the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY). Results The maternal near-miss incidence ratio was 16.6/1000 live births, the maternal near-miss to mortality ratio was 1.9:1, and the mortality index was 0.34%. Hypertensive disorders of pregnancy were the most common causes of near-miss events (45.8%) followed by hemorrhage (23.6%) in this study. Conclusions Hypertensive disorders in pregnancy and hemorrhage were the two leading causes of near-miss events and mortality followed by sepsis. As the near-miss analysis indicates, the quality of health care and causes are almost similar to maternal mortality, so its registry should be done along with maternal mortality.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia.

OBJECTIVES: To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution. DESIGN: A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications. SETTING: Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included. MEASUREMENTS: The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care. RESULTS: In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function. CONCLUSIONS: In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations. IMPLICATIONS FOR PRACTICE: The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017.

BACKGROUND: Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI). METHODS: In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety. RESULTS: In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease. CONCLUSION: Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.

An easily applicable single condition-based mortality index for patients undergoing radical prostatectomy or radical cystectomy.

PURPOSE: There is no generally accepted instrument to measure comorbidity in patients with cancer. We determined which single comorbid conditions are independently associated with competing mortality after radical prostatectomy or radical cystectomy in order to develop a mortality index. METHODS: The study samples consisted of 2,961 consecutive patients who underwent radical prostatectomy between 1992 and 2007 for clinically localized prostate cancer and 932 consecutive patients who underwent radical cystectomy between 1993 and 2012 for high-risk non-muscle-invasive or muscle-invasive urothelial or undifferentiated bladder cancer. Competing mortality was the study endpoint. Proportional hazard models for the subdistribution of competing risks were used for analysis. RESULTS: Age, angina pectoris, peripheral vascular disease, cerebrovascular disease, chronic lung disease, diabetes mellitus, moderate or severe renal disease, current smoking, and American Society of Anesthesiologists (ASA) physical status class 3 to 4 were independent predictors of competing mortality after radical prostatectomy. After identifying radical cystectomy, age, angina pectoris, chronic lung disease, diabetes mellitus, current smoking, ASA class 3 to 4, and male sex as independent predictors of competing mortality, a combined mortality index using the conditions independently associated with competing mortality in both samples stratified the patients into risk groups with 0% 10-year competing mortality in the lowest and approximately 50% in the highest-risk classes. CONCLUSIONS: This simple and plausible combined mortality index based on age, ASA class, smoking status, and the presence of the conditions such as angina pectoris, chronic lung disease, and diabetes mellitus may be used to predict competing mortality in candidates for radical prostatectomy or radical cystectomy.

Evaluation of obstetric near miss and maternal deaths in a tertiary care hospital in north India: shifting focus from mortality to morbidity.

OBJECTIVE: Near miss audit improves understanding of determinants of maternal morbidity and mortality and identifies areas of substandard care. It helps health professionals to revise obstetric policies and practices. METHODS: A retrospective review of obstetric case records was performed to assess frequency ad nature of maternal near miss (MNM) cases as per WHO criteria. For each case, primary obstetric complication leading to maternal morbidity was evaluated. Obstetric complications were analyzed to calculate prevalence ratio, case fatality ratio, and mortality index. RESULTS: There were 6,357 deliveries, 5,273 live births, 247 maternal deaths, and 633 MNM cases. As per WHO criteria for Near miss, shock, bilirubin >6 mg%, and use of vasoactive drugs were the commonest clinical, laboratory, and management parameters. Hemorrhage and hypertensive disorders of pregnancy were leading cause of MNM (45.7 and 24.2 %) and maternal deaths (28.7 and 21.5 %). Highest prevalence rate, case fatality ratio, and mortality index were found in hemorrhage (0.53), respiratory diseases (0.46), and liver disorders (51.9 %), respectively. CONCLUSION: Developing countries carry a high burden of maternal mortality and morbidity which may be attributed to improper management of obstetric emergencies at referring hospitals, poor referral practices, and poor access/utilization of health care services.