The description of outcomes in Medicare patients hospitalized with peptic ulcer disease.

OBJECTIVE: The objective of this study was to describe outcomes of care for Medicare patients hospitalized with peptic ulcer disease from 1992 through 1997 and to identify factors related to cost, length of stay, and readmission rates. METHODS: General descriptive statistics were obtained from Medicare inpatient claims data by year, endoscopy grouping, diagnosis related group code, and principal diagnosis code. From abstracted clinical data, associations were derived for length of stay, readmission rates, and the following processes of care: screening or treatment for Helicobacter pylori; screening for nonsteroidal antiinflammatory drug (NSAID) use; and the performance of endoscopy. The Acute Physiology and Chronic Health Evaluation method was used to estimate patient health status for the study. RESULTS: During the 6-yr study, there were 878,212 claims, which constituted 1.3% of the total Medicare claims. The total Medicare payment for peptic ulcer claims was estimated at $4.8 billion. The inpatient mortality rate was 4.5%. Readmission rates remained relatively constant during the study period but decreased significantly when NSAID screening was documented during the hospitalization. Admission rates, length of stay, and mortality declined progressively during the study period. A reduction in length of stay of approximately 1 day was observed when screening or treatment for H. pylori, screening for NSAID use, or the performance of endoscopy was documented. CONCLUSIONS: Peptic ulcer disease has an important impact on the Medicare population with respect to cost, recurrence, and mortality. Adherence to selected processes of care is associated with shorter length of stay and lower readmission rates.

Screening for Helicobacter pylori and nonsteroidal anti-inflammatory drug use in medicare patients hospitalized with peptic ulcer disease.

BACKGROUND: Peptic ulcer disease has well-defined causes, with most cases related to Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use. OBJECTIVES: To report performance rates on measures of care related to peptic ulcer disease in hospitalized Medicare patients and to identify improvement opportunities. METHODS: Retrospective study of 2267 Medicare beneficiaries hospitalized with peptic ulcer disease. Data were obtained from 2 sources: medical records (n = 1580) from 80 hospitals--16 hospitals in each of 5 states (Alabama, Florida, Louisiana, Tennessee, and Texas)-and a national random sample (n = 687). Three measures of care were evaluated: (1) rate of diagnostic screening or treatment for H. pylori infection, (2) rate of screening for nonsteroidal anti-inflammatory drug use on admission to the hospital, and (3) rate of assessment of risk factors for recurrence. RESULTS: The rate of screening or treatment for H. pylori infection was 52.9% to 59.8% among the 5 states and 55.6% in the national random sample. The rate of screening for nonsteroidal anti-inflammatory drug use was 64.6% to 75.4% among the states and 73.4% in the national random sample. The rate of assessment at discharge from the hospital for additional risks for ulcer recurrence was 66.1% to 73.6% among the states and 70.9% in the national random sample. CONCLUSIONS: Based on hospital records, slightly more than half of the Medicare patients admitted with diagnoses studied are being considered for H. pylori eradication. If recurrence of this disease is to be reduced, physicians must adopt current screening and treatment recommendations.

Directional atherectomy in iliac stent failure: clinical technique and histopathologic correlation.

PURPOSE: To assess the feasibility and efficacy of directional atherectomy in the treatment of iliac stent stenosis or occlusion and to evaluate the histologic composition of excised atherectomy specimens. METHODS: Directional atherectomy of six occluded and 10 severely stenosed iliac stents was undertaken in 12 patients at a mean interval of 28 months (range 3-69 months) after stent insertion for occlusive aortoiliac disease. In cases of stent occlusion, atherectomy was preceded by low-dose thrombolysis. In all patients stent clearance with return of femoral pulses was achieved within 24 hr and there were no significant complications. All excised specimens were sent for histologic examination. RESULTS: Eleven patients (92%) remain symptom free with unlimited walking distance at a mean follow-up interval of 11.5 months (range 3-31 months) after treatment. Histologic examination revealed typical myointimal hyperplasia at three excision sites, intimal fibrosis at three sites, atheroma at four sites and organized thrombus at six sites. CONCLUSION: Atherectomy offers an effective treatment in iliac stent occlusion and restenosis with no significant adverse effects. Debulking of these lesions seems to offer a more logical approach than simple balloon angioplasty. Clinical and duplex follow-up confirms satisfactory outcome within the first year but longer-term results are not yet known. The histologic data obtained demonstrate that stent restenosis and occlusion are likely to be multifactorial, and challenge the assumption that myointimal hyperplasia is the sole cause of iliac stent occlusion.

Effects of timely antibiotic administration and culture acquisition on the treatment of urinary tract infection.

The purpose of this study was to assess the timeliness of initial antibiotic administration and culture acquisition for Medicare patients discharged with a principal diagnosis of urinary tract infection. The main outcome measurement was reduced length of stay. Data were collected retrospectively from 24,389 randomly selected discharged Medicare patients from September 1, 1994, to August 31, 1995. Only 61% of the cases as urinary tract infection had adequate criteria to confirm the diagnosis. Of these cases, antibiotics were administered within 4 hr after presentation in 40.9% patients. Urine cultures within 24 hr of presentation were noted more frequently (94%)than blood cultures (66%). Urine cultures obtained before antibiotic administration were noted more frequently (82%) than were blood cultures (58%). Timely antibiotic administration and the acquisition of urine cultures in the first 24 hr of hospitalization were independently associated with shorter length of stay.

Evaluation of two intervention strategies to stimulate quality improvement projects in the hospital: the H. pylori example.

A multistate quality improvement project conducted to improve the care of hospitalized Medicare patients with peptic ulcer disease is described. This randomized control study design compared the effectiveness of two intervention strategies (mailed information vs. on-site presentations with feedback) in stimulating hospitals to conduct diagnostic journeys to determine root causes for performance deficits and to develop and implement plans to improve performance.

Adherence to Agency for Health Care Policy and Research guidelines for benign prostatic hyperplasia.

PURPOSE: We determined adherence rates to guideline recommendations for the diagnosis and treatment of benign prostatic hyperplasia published and distributed by the Agency for Health Care Policy and Research in 1994. MATERIALS AND METHODS: Measures of care were developed based upon Agency for Health Care Policy and Research guideline recommendations approved by the Health Care Financing Administration and the American Urological Association (AUA). A random 4-state sample of 2,000 inpatient records with a principal diagnosis of hyperplasia of the prostate (ICD-9-CM code 600) and principal procedure code of 60.2 was selected by the Health Care Financing Administration and abstractions were performed. We assessed reliability and validity and determined results for each of the following measures of care: 1) documentation of indications for a transurethral resection of the prostate; 2) documentation of appropriate preoperative assessment; 3) documentation of indications for an inpatient excretory urogram (IVP) and/or sonogram when the procedures were performed and 4) documentation of surgical time and grams of tissue removed. Adherence rates for all measures of care were determined. RESULTS: Of the 4-state sample of inpatient cases 1,828 cases met entry criteria for the study. Of the cases 93% had at least 1 symptom and/or score, and/or an anatomical abnormality documented before surgery. An AUA score was documented in the inpatient medical record in 7.5% of the cases. Recommendations for preoperative evaluation included urinalysis, a digital rectal exam and determination of preoperative creatinine. All of these were documented in 475 (26%) cases. Of the 1,828 cases 216 (12%) had an IVP or sonogram performed in the inpatient setting. In 36% indications were documented when sonograms were performed; 74% had documented indications when IVPs were performed. Excluding laser transurethral resections of the prostate, surgical time and tissue amounts were documented and recorded in 1,424 transurethral resections of the prostate cases (91%). CONCLUSIONS: Adherence to selected Agency for Health Care Policy and Research guideline recommendations is documented infrequently in the medical record.

Squamous-cell carcinoma of the proximal colon: report of a case and review of the literature.

A case of an undoubted squamous-cell carcinoma arising at the hepatic flexure in the colon of a middle-aged man is reported. Review of the literature and exclusion of cases not strictly comparable suggest that pure squamous-cell carcinoma of the colon is rare, this being only the fifteenth such tumor reported, and only the second recorded case of such a tumor of the hepatic flexure. Possible pathogenesis is suggested.