Do pre-existing complications affect the failure to rescue quality measures?

BACKGROUND: A project sponsored by the University Health System Consortium has addressed the inaccuracy and high variability across institutions concerning the use of the failure to rescue (FTR) quality indicator defined by the Agency for Healthcare Research and Quality (AHRQ). Results indicated that of the complications identified by the quality indicator, 29.5% were pre-existing upon hospital admission. OBJECTIVE: The purpose of our study was to investigate the possible bias to FTR measures by including cases of complications that were pre-existing at admission. METHODS: Hospital discharges between 1 January 1996 and 30 September 2007 were retrospectively gathered from administrative databases. Using definitions outlined by the AHRQ and the National Quality Forum (NQF), FTR rates were calculated. Using present on admission coding, FTR rates were recalculated to differentiate between the rates of pre-existing and that of acquired cases. RESULTS: Using the AHRQ definition, the overall FTR rate was 11.60%. The FTR rate for patients with pre-existing complications was 8.85%, whereas patients with complications acquired during hospitalisation had an FTR rate of 18.46% (p<0.001). The NQF FTR rate was 9.93%. Pre-existing and acquired FTR rates using the NQF measure were 9.42% and 12.77%, respectively (p<0.001). CONCLUSIONS: Current definitions of FTR measures meant to identify inhospital complications appear biased by the inclusion of problems at admission. Furthermore, many patients with these complications are excluded from the algorithms. When taking into account the timing of the "complications", these measures can be useful for internal quality control. However, it should be stressed that the usefulness of the measures to compare institutions will be dependent on coding practices of institutions. Validation using chart review may be required.

Secular trends in hip fracture incidence and recurrence.

UNLABELLED: The decline in hip fracture incidence is now accompanied by a further reduction in the likelihood of a recurrent hip fracture among survivors of the first fracture. INTRODUCTION: Hip fracture incidence is declining in North America, but trends in hip fracture recurrence have not been described. METHODS: All hip fracture events among Olmsted County, Minnesota residents in 1980-2006 were identified. Secular trends were assessed using Poisson regression, and predictors of recurrence were evaluated with Andersen-Gill time-to-fracture regression models. RESULTS: Altogether, 2,752 hip fractures (median age, 83 years; 76% female) were observed, including 311 recurrences. Between 1980 and 2006, the incidence of a first-ever hip fracture declined by 1.37%/year for women (p < 0.001) and 0.06%/year for men (p = 0.917). Among 2,434 residents with a first-ever hip fracture, the cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men with death treated as a competing risk. Age and calendar year of fracture were independently associated with hip fracture recurrence. Accounting for the reduction in first-ever hip fracture rates over time, hip fracture recurrence appeared to decline after 1997. CONCLUSION: A recent reduction in hip fracture recurrence is somewhat greater than expected from the declining incidence of hip fractures generally. Additional research is needed to determine the extent to which this can be attributed to improved patient management.

Patient satisfaction associated with correct identification of physician's photographs.

OBJECTIVE: To determine whether placement of photographs of physicians in hospital rooms improves patients' satisfaction with their medical care. PATIENTS AND METHODS: This is a prospective, controlled study of 224 patients admitted to general internal medicine services in a teaching hospital. The intervention consisted of photographs (8 x 10 in) of attending and resident physicians displayed in the patients' rooms. Before dismissal, patients completed a survey that required them to match names with photographs of physician caregivers and included patient satisfaction questions. The primary outcome was whether patients who had photographs in their hospital room would correctly identify more physicians than those with no photographs in their room. RESULTS: The presence of photographs on the hospital wall was associated with a significant improvement in the number of physicians identified correctly (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.47-2.27; P<.001). The percentage of physicians that patients identified by correctly matching their physicians' names to their photographs was significantly associated with satisfaction with physician responsiveness (OR, 1.19; 95% CI, 1.01-1.40; P=.03) and with the way in which physicians addressed questions regarding medical care (OR, 1.23; 95% CI, 1.05-1.44; P=.05). CONCLUSIONS: Patients who had photographs of their physicians on the wall of their hospital room were able to identify correctly a larger number of physicians on their team compared with patients who had no photographs. Patient satisfaction was related to the number of physicians' photographs that patients could identify correctly.

Medical care of elderly patients with hip fractures.

Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.