Are structural characteristics of programs and hospitals associated with 100-day readmission of hematopoietic SCTs in Taiwan?

Hematopoietic SCT (HSCT) is one treatment modality for hematological malignancies. It is increasingly common but remains centralized in certain hospitals wherein procedures and protocols can vary. This study examined 100-day readmission for patients with hematological malignancies undergoing HSCT in Taiwan from the years 2001 to 2006. Of particular interest was an examination of how HSCT program characteristics might influence outcomes. This population-based retrospective cohort study with longitudinal follow-up used Taiwan's National Health Insurance Research Database. A generalized linear model with a logistic-dependent variable representing being admitted or not admitted was used to model 100-day readmission, adjusting for the nested design. There were 718 HSCT recipients for hematological malignancies in the 5-year study period from 10 HSCT programs. In spite of the average length of stay of 43.71 days (s.d.=25.75) days, 52% of recipients were readmitted within 100 days of discharge. Ownership status, the number of HSCT hematologists, and the ratio of HSCT procedures to HSCT hematologists independently predicted 100-day readmission after adjusting for clustered data and controlling for recipient characteristics.

Do mental disorders matter? A study of absenteeism among care seeking Gulf War veterans with ill defined conditions and musculoskeletal disorders.

AIMS: To investigate the extent that common psychological conditions contribute to lost work among individuals with musculoskeletal and ill defined conditions. METHODS: Cross sectional health and work related survey evaluating Gulf War veterans seeking Department of Defense health care for Gulf War related health concerns. Ordered probit models were used to study whether a provider diagnosed musculoskeletal condition (ICD-9 codes 710-739) or "signs, symptoms, and ill defined conditions" (ICD-9 codes 780-799) have an effect on recent lost work over the previous 90 days in the presence of one or more psychological conditions (ICD-9 codes 290-320) after controlling for sociodemographic variables. RESULTS: Bivariate analyses revealed that musculoskeletal conditions, ill defined conditions, and psychological conditions were positively associated with lost work. Multivariate analyses showed an independent effect of both psychological conditions and musculoskeletal conditions. A significant interaction existed between psychological conditions and musculoskeletal conditions: the presence of a coexisting psychological condition considerably increased the likelihood that a musculoskeletal disorder resulted in lost work, or vice versa. CONCLUSIONS: Psychological conditions appear to be an important contributor to absenteeism among individuals with musculoskeletal and ill defined conditions. A limitation of the cross sectional design was the inability to sequence the onset of conditions.

Outpatient mastectomy: clinical, payer, and geographic influences.

OBJECTIVE: To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and state on the use of outpatient services for complete mastectomy in light of state and federal length-of-stay managed care legislation. DATA SOURCES: Healthcare Cost and Utilization Project representing all discharges from hospitals and ambulatory surgery centers for five states (Colorado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990-96). STUDY DESIGN: Longitudinal, cross-sectional analyses of all women undergoing inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient CMAS was determined from multivariate models, adjusting for clinical characteristics (age < 50 years, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). PRINCIPAL FINDINGS: In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 to 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medicaid, or private commercial insurance were less likely to receive an outpatient CMAS compared to women with an HMO payer. CONCLUSIONS: LUMP is an outpatient procedure, and STMAS is becoming primarily outpatient. CMAS, while still primarily inpatient, is increasingly outpatient in some states. Although clinical characteristics remain important, the state in which a woman receives care and whether she has an HMO payer are strong determinants of whether she receives an outpatient CMAS.

Orientation to the critical care unit. The value of preceptor programs.

Effective orientation is vital to the critical care team in providing quality patient care in today's health care environment. Preceptorship is the ideal method of providing orientation, and preceptors are key to effective implementation of the program. With limits to the resources available today, modifications to preceptorship can improve the frequency of providing quality orientation.

A rural cancer outreach program lowers patient care costs and benefits both the rural hospitals and sponsoring academic medical center.

The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.

Quality indicators using hospital discharge data: state and national applications.

BACKGROUND: Demand for information about the quality of health care has escalated. Yet many organizations lack well-specified quality measures, statistical expertise, or the requisite data to produce such information. The Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs) represent one approach to measuring health care quality using readily available data on hospital inpatients. METHODS: The HCUP QIs, developed in 1994, address clinical performance rather than other dimensions of quality such as satisfaction or efficiency. The 33 indicators produce rates that represent measures of outcomes (mortality and complications), utilization, and access. In lieu of complex multivariate techniques, two methods were used: (1) restrictions in defining patient subgroups to isolate homogeneous at-risk populations and (2) standardization when populations are diverse. Stratified analyses are recommended when patient or hospital factors are believed to influence the outcome. A simple method for making statistical comparisons to national rates was developed. The HCUP QI software, available in both mainframe and microcomputer applications, have enabled organizations to use their own data to produce comparative statistics and examine trends over time. Results summarized at the individual hospital or aggregate level are being used to stimulate continuous quality improvement initiatives. CONCLUSIONS: The HCUP QIs offer a low-cost alternative for organizations that have access to administrative data. Current users include hospital associations, state health departments, statewide data organizations, and individual hospitals. Although the HCUP QIs are intended to serve as indicators, not definitive measures, of quality, they were designed to highlight quality concerns and to target areas for more intensive study.

The case for national health data standards.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains groundbreaking provisions to encourage the development of a national health information system through the establishment of standards. This paper compares statewide inpatient data systems to one standard--the Uniform Bill (UB)--to understand how standards have been used and how they can be improved. We recommend changes to the UB, note the need for better compliance, and suggest new standards for common, derived elements.

The ABCs of teaching advanced cardiac life support.

This article describes the evolution in methods used at The Christ Hospital in Cincinnati, Ohio, to teach advanced cardiac life support over the past 10 years. The interactive nature of the teaching methods has improved participants' enjoyment of this course. With smaller teaching groups, instructors find this course challenging and fun to teach. This article provides outlines of teaching stations at The Christ Hospital and examples in which to implement the current advanced cardiac life support content according to the American Heart Association's teaching recommendations.

All-payer severity-adjusted diagnosis-related groups: a uniform method to severity-adjust discharge data.

Measuring severity of illness within diagnosis-related groups (DRGs) has become increasingly important because of the growing need to compare outcomes across providers. In response to these needs, the Health Care Financing Administration (HCFA) has developed a DRG-based severity system as a refinement to its current Medicare DRG structure. As a result of this recent HCFA research, all-payer severity-adjusted DRGs (APS-DRGs) have been developed to provide a uniform approach for severity classification that is also applicable to the all-payer population.

Treating early-stage breast cancer: hospital characteristics associated with breast-conserving surgery.

Despite growing acceptance of the fact that women with early-stage breast cancer have similar outcomes with lumpectomy plus radiation as with mastectomy, many studies have revealed the uneven adoption of such breast-conserving surgery. Discharge data from the Hospital Cost and Utilization Project, representing multiple payers, locations, and hospital types, demonstrate increasing trends in breast-conserving surgery as a proportion of breast cancer surgeries from 1981 to 1987. Women with axillary node involvement were less likely to have a lumpectomy, even though consensus recommendations do not preclude this form of treatment when local metastases are present. Non-White race, urban hospital location, and hospital teaching were associated with an increased likelihood of having breast-conserving surgery.

Education day. The evolution of a learning experience.

Education Day in our hospital was created as a way of increasing attendance at annual mandatory inservices. Since beginning the program, compliance with mandatory inservice has increased from 50% to 97%. The Education Day format consolidates resources and provides consistency in the delivery of required information. The format is also flexible; it responds to changes and specialized educational needs of the nursing staff.