Screening inpatient quality using post-discharge events.

BACKGROUND: Decreasing hospital lengths of stay (LOS) hamper efforts to detect and to definitively treat complications of care. Patients leave before some complications are identified. OBJECTIVES: To develop a computerized method to screen for hospital complications using readily available administrative data from outpatient and nonacute care within 90 days of discharge. DESIGN: We developed the Complications Screening Program for Outpatient data (CSP-O) by using diagnosis and procedure codes from Medicare Part A and B claims to define 50 complication screens. Seventeen apply to specific procedural cases, and 33 apply to all adult, acute, medical, or surgical hospitalizations. The CSP-O algorithm examined outpatient, physician office, home health agency, and hospice claims within 90 days following discharge. SUBJECTS: Seven hundred thirty nine thousand, two hundred and forty eight discharges of Medicare beneficiaries (age range, > or = 65 years) were admitted to 515 hospitals nationwide in 1994. RESULTS: Complete 90-day, post-discharge windows were present for 62.8% of all and 68.5% of procedural cases. The 33 general screens flagged 13.6% of all cases; only 1.8% of procedural cases were flagged by the 17 procedural screens. When we allowed the CSP-O algorithm to scan information from acute hospital readmissions, flag rates rose to 32.8% for general and 8.7% for procedural complications. Controlling for patient and hospital characteristics, flag rates were considerably higher among the very old and at small and for-profit institutions. CONCLUSIONS: Whereas several CSP-O findings have construct validity, limitations of claims raise concerns. Regardless of the CSPO's ultimate utility, examining post-discharge experiences to identify inpatient complications remains important as LOSs fall.

Molecular species of lecithins in human gallbladder bile.

Using a precise high performance liquid chromatography (HPLC) technique, we identified the molecular species of lecithins in gallbladder biles from patients with cholesterol gallstones (n = 29), pigment gallstones (n = 9), morbid obesity (n = 5), and "controls" (n = 10). The major lecithin species identified in all groups, in descending rank order as represented by the fatty acids in the sn-1 and sn-2 positions, were 16:0-18:2, 16:0-18:1, 16:0-20:4, 18:0-18:2, and 18:1-18:2. Lecithin species were found to be more numerous and in substantially different proportions than reported by previous investigators. No significant differences were found between any biliary lecithin species in the cholesterol and pigment stone groups. However, compared with controls, both cholesterol and pigment stone patients had smaller proportions of 16:0-20:4, the principal arachidonyl lecithin species. Using the HPLC elution sequence for quantifying the hydrophilic-hydrophobic balance, we developed a Hydrophobic Index for lecithin species in each bile based upon the principles proposed by D. M. Heuman for bile salt species. Hydrophobic indices of bile salts and lecithin were positively correlated (r = 0.48, R2 = 0.23, P = 0.0002) suggesting that more hydrophobic bile salts were associated with biliary secretion of more hydrophobic lecithins. The most hydrophobic major lecithin species, 18:0-18:2, was present in greater proportions in biles with cholesterol monohydrate crystals in their sediments and in those with cholesterol saturation indices greater than one. This work provides rigorous separation, identification, and quantitation of the lecithin species in human gallbladder bile from a large cohort of patients but, apart from a more hydrophobic bile salt pattern coupling more hydrophobic lecithins, we fail to identify any relationships of biomedical importance between lecithin species and other major biliary constituents.