A Cross-sectional Study of Hospital Performance on ICU Utilization Practices for Patients with Chronic Obstructive Pulmonary Disease.

PURPOSE: Intensive care unit (ICU) resources are a costly but effective commodity used in the management of critically ill patients with chronic obstructive pulmonary disease (COPD). ICU admission decisions are determined by patient diagnosis and severity of illness, but also may be affected by hospital differences in quality and performance. We investigate the variability in ICU utilization for patients with COPD and its association with hospital characteristics. METHODS: Using a 3M administrative dataset spanning 2008-2013, we conducted a retrospective cohort study of adult patients discharged with COPD at hospitals in three state to determine variability in ICU utilization. Quality metrics were calculated for each hospital using observed-to-expected (O/E) ratios for overall mortality and length of stay. Logistic and multilevel multivariate regression models were constructed, estimating the association between hospital quality metrics on ICU utilization, after adjustment for available clinical factors and hospital characteristics. RESULTS: In 434 hospitals with 570,517 COPD patient visits, overall ICU admission rate was 33.1% [range 0-89%; median (IQR) 24% (8, 54)]. The addition of patient, hospital, and quality characteristics decreased the overall variability attributable to individual hospital differences seen within our cohort from 40.9 to 33%. Odds of ICU utilization were increased for larger hospitals and those seeing lower pulmonary case volume. Hospitals with better overall O/E ratios for length of stay or mortality had lower ICU utilization. CONCLUSIONS: Hospital characteristics, including quality metrics, are associated with variability in ICU utilization for COPD patients, with higher ICU utilization seen for lower performing hospitals.

Evaluation of direct-to-consumer low-volume lab tests in healthy adults.

BACKGROUND: Clinical laboratory tests are now being prescribed and made directly available to consumers through retail outlets in the USA. Concerns with these test have been raised regarding the uncertainty of testing methods used in these venues and a lack of open, scientific validation of the technical accuracy and clinical equivalency of results obtained through these services. METHODS: We conducted a cohort study of 60 healthy adults to compare the uncertainty and accuracy in 22 common clinical lab tests between one company offering blood tests obtained from finger prick (Theranos) and 2 major clinical testing services that require standard venipuncture draws (Quest and LabCorp). Samples were collected in Phoenix, Arizona, at an ambulatory clinic and at retail outlets with point-of-care services. RESULTS: Theranos flagged tests outside their normal range 1.6× more often than other testing services (P < 0.0001). Of the 22 lab measurements evaluated, 15 (68%) showed significant interservice variability (P < 0.002). We found nonequivalent lipid panel test results between Theranos and other clinical services. Variability in testing services, sample collection times, and subjects markedly influenced lab results. CONCLUSION: While laboratory practice standards exist to control this variability, the disparities between testing services we observed could potentially alter clinical interpretation and health care utilization. Greater transparency and evaluation of testing technologies would increase their utility in personalized health management. FUNDING: This work was supported by the Icahn Institute for Genomics and Multiscale Biology, a gift from the Harris Family Charitable Foundation (to J.T. Dudley), and grants from the NIH (R01 DK098242 and U54 CA189201, to J.T. Dudley, and R01 AG046170 and U01 AI111598, to E.E. Schadt).

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

BACKGROUND: Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. PURPOSE: We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. METHODOLOGY/APPROACH: The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. FINDINGS: The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. PRACTICAL IMPLICATIONS: The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

BACKGROUND: Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. PURPOSE: We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. METHODOLOGY/APPROACH: The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. FINDINGS: The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. PRACTICAL IMPLICATIONS: The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

The effects of capital and human resource investments on hospital performance.

Data are employed from a sample of New York hospitals and the Hospital Consumer Assessment Healthcare Providers and Systems database to analyze the effects of capital spending, staffing levels, and salaries on hospital performance. The most striking result is that higher average salaries are associated with lower length of stay, lower mortality rate, and higher satisfaction but are not significantly related to cost per patient. Therefore, it appears that human resource investments may be associated with better patient outcomes without significantly increasing the cost of patient care.

Efficacy of 2 finishing protocols in the quality of orthodontic treatment outcome.

INTRODUCTION: The objectives of this prospective clinical study were to evaluate the quality of treatment outcomes achieved with a complex orthodontic finishing protocol involving serpentine wires and a tooth positioner, and to compare it with the outcomes of a standard finishing protocol involving archwire bends used to detail the occlusion near the end of active treatment. METHODS: The complex finishing protocol sample consisted of 34 consecutively treated patients; 1 week before debonding, their molar bands were removed, and serpentine wires were placed; this was followed by active wear of a tooth positioner for up to 1 month after debonding. The standard finishing protocol group consisted of 34 patients; their dental arches were detailed with archwire bends and vertical elastics. The objective grading system of the American Board of Orthodontics was used to quantify the quality of the finish at each time point. The Wilcoxon signed rank test was used to compare changes in the complex finishing protocol; the Mann-Whitney U test was used to compare changes between groups. RESULTS: The complex finishing protocol group experienced a clinically significant improvement in objective grading system scores after treatment with the positioner. Mild improvement in posterior space closure was noted after molar band removal, but no improvement in the occlusion was observed after placement of the serpentine wires. Patients managed with the complex finishing protocol also had a lower objective grading system score (14.7) at the end of active treatment than did patients undergoing the standard finishing protocol (23.0). CONCLUSIONS: Tooth positioners caused a clinically significant improvement in interocclusal contacts, interproximal contacts, and net objective grading system score; mild improvement in posterior band space was noted after molar band removal 1 week before debond.

Operational and contextual drivers of hospital costs.

PURPOSE: The purpose of this paper is to examine empirically how operational performance and contextual factors contribute to differences in overall patient care costs across different hospitals. DESIGN/METHODOLOGY/APPROACH: Administrative data are employed from a sample of hospitals in New York State to construct measures of contextual factors, operational performance, and cost per patient. Operational performance and cost variables are adjusted to account for case mix differences across hospitals. Hierarchical regression is used to analyze the effects of contextual and operational variables on cost performance. FINDINGS: Increased length of stay, increased patient volume, and educational mission were associated with higher cost per patient. Mortality performance was associated with lower cost per patient. However, it was not found that location, size, or ownership status had a significant relationship with cost performance. PRACTICAL IMPLICATIONS: This paper identifies several significant relationships between contextual and operational variables and hospital costs. From a managerial perspective, these findings highlight the fact that some drivers of cost in hospitals are under the control of managers. One of the primary cost drivers in the study is length of stay, which implies that there is significant room for improvement in healthcare performance through a focus on operational excellence. ORIGINALITY/VALUE: For researchers, the present study highlights the relative importance of operational versus contextual factors, with respect to cost performance in hospitals. The results of this study also provide direction for additional research into the role operational performance might play in determining the overall organizational performance in a hospital.

Exploring strategies for reducing hospital errors.

The purpose of this study is to explore current strategies for reducing errors at U.S. hospitals. Reports by the Institute of Medicine highlight concerns about the staggering number of medical errors that occur in the U.S. healthcare system. These reports have exerted considerable pressure on hospitals to establish programs that reduce errors and improve patient safety. A previous research study identifies seven critical strategies for reducing hospital errors based on a case study of four Chicago-area hospitals. These strategies include (1) partnership with stakeholders, (2) reporting errors free of blame, (3) open discussion of errors, (4) cultural shift, (5) education and training, (6) statistical analysis of data, and (7) system redesign. This article reports the results of our nationwide survey of 525 hospitals. We examined the perceptions of healthcare quality directors about the importance of these seven patient safety strategies, the factors that act as barriers, the level of adoption of these strategies, and the benefits resulting from implementation of these strategies. Our results indicate that a considerable gap exists between current hospital practices and the perceived importance of various approaches to improving patient safety. Results of our regression analysis reveal that internal organizational barriers are associated with a larger gap between perceived importance and actual implementation. Moreover, the regression analysis also reveals that smaller gaps are associated with better error outcomes such as reduction in the frequency and severity of errors. The findings provide specific directions for enhancing patient safety programs at hospitals in the future.

Germinal choice technology and the human future.

This paper examines the likely impacts of emerging technologies that will give prospective parents the potential to directly influence the genetics of their offspring. My primary focus is on advanced prenatal genetic diagnosis (PGD) for both disease and non-disease traits, since this is likely to emerge before such possibilities as direct germline engineering. I place these technologies within the larger context of today's revolution in the life sciences and consider the progress likely to occur in this realm in the next few generations. I take a common sense look at the types of screening choices people are likely to make once these possibilities become possible, their broad consequences for human society, and the advantages and disadvantages of plausible regulatory paths in this realm. I also reflect upon today's debate about cloning and other such issues in the life sciences, looking at the driving forces behind these discussions and the tensions likely to develop in the next few decades.

Would doubling the human lifespan be a net positive or negative for us, either as individuals or as a society? Point-counterpoint.

There is a significant possibility that over the next few decades science will make discoveries of a kind that might allow the doubling of the average human life span, from roughly 76 years now to 150. This development would, for many, represent the realization of a dream: that of enabling people to live much longer lives than at present, holding back death, which has often been seen as an ancient, unbeatable enemy. It would also raise a large number of unprecedented individual and social problems: Would we really want to live to 150? Is such a goal ethical? What would this putative longevity do to our present social structures and arrangements? Would we get a better society or a worse one?

The pitfalls of planning for demographic change.

As we begin to understand the biology of aging, it will be ever more tempting to try to plan for the social consequences of the coming biomedical interventions in this arena. However, this will remain a daunting task, because the larger consequences of the arrival of antiaging interventions will greatly depend on the relative character and timing of the specific procedures that emerge. Three basic classes of interventions are likely: ones that slow aging in adults, ones that reverse aging in adults, and embryonic interventions that modify the overall trajectory of human aging. The consequences of each will differ significantly in the time required before noticeable demographic shifts begin to manifest in the human population, and in the social and political changes the interventions evoke. The specific societal consequences generally will arrive long before the demographic ones, and will hinge on the technical details of the interventions themselves--their complexity, physiological targets, modes of delivery, costs, unpleasantness, and the character and frequency of side effects.