Impact of intercurrent respiratory infections on lung health in infants born <29 weeks with bronchopulmonary dysplasia.

OBJECTIVE: Assess the impact of intercurrent respiratory infections in infants <29 weeks gestational age (GA). STUDY DESIGN: A retrospective cohort study of 111 infants born <29 weeks GA, controlling for bronchopulmonary dysplasia (BPD) severity and assessing pulmonary health over the first year of life through oxygen, diuretic and inhaled steroid use. RESULT: Regression analysis showed viral infections increased oxygen use (odds ratio (OR) of 15.5 (confidence interval (CI)=3.4, 71.3)). The trend test showed increasing numbers of viral infections were associated with increased oxygen (OR (95% CI)=6.4 (2.3 to 17.4), P=0.0003), diuretic (OR (95% CI)=2.4 (1.1to 5.2), P=0.02) and inhaled steroid use (OR (95% CI)=2.2 (1.003 to 5.2), P=0.049), whereas bacterial infections were not. CONCLUSION: Viral infections caused more long-term pulmonary morbidity/mortality than bacterial infections on premature lung health, even when controlling for BPD.

Comparing methods to identify hip fracture in a nursing home population using Medicare claims.

UNLABELLED: The inpatient principal diagnosis in Medicare claims identified 96% of hip fractures in hospitalized nursing home residents with high rates of confirmation by other claims files. INTRODUCTION: Hip fracture is typically identified in Medicare claims by examining only the principal diagnosis in the inpatient file, but this simple approach might be inadequate for nursing home residents. Our objective was to examine the impact of varied operational definitions for identifying hip fracture hospitalizations in administrative claims data. METHODS: We conducted a retrospective examination of Medicare inpatient and outpatient claims data for dually Medicaid- and Medicare-eligible nursing home residents in 1999 in California, Florida, Missouri, New Jersey, and Pennsylvania (n = 197,514). We determined the number of hip fractures identified in inpatient (Medicare A) diagnoses codes using differing definitions that varied according to whether or not hip fracture was required to be the principal diagnosis and whether or not confirmatory imaging and procedure codes were required to be found in other (Medicare B) claims files. RESULTS: Hip fractures were found in any inpatient diagnosis position in 4,680 subjects, with 4,479 of these found in the principal diagnosis position. With either approach to diagnosis position, confirmatory imaging and procedure codes were identified for 95% of persons hospitalized with hip fracture. CONCLUSION: The principal diagnosis alone will identify 96% of hip fracture diagnoses in hospitalized nursing home residents. Such diagnoses are confirmed at very high rates by other sources of claims data. Researchers may be confident using a simple approach to identifying hip fracture hospitalizations in this population, using inpatient claims alone and interrogating only the principal diagnosis position.

Hyperglycaemia and mortality of diabetic patients with candidaemia.

AIMS: To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia. METHODS: A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality. RESULTS: During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03]. CONCLUSION: Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.

Fecal occult blood test use by Kansas medicare beneficiaries.

PURPOSE: The aim of this study was to examine utilization of and trends in fecal occult blood testing (FOBT) among beneficiaries since Medicare began FOBT coverage on January 1, 1998. METHODS: We identified Kansas Medicare beneficiaries ages 65-79. Using Medicare claims, we determined which beneficiaries received FOBT during 1998-1999. We examined demographic variables associated with FOBT and rate changes over time. We linked beneficiaries to primary care practices (PCPs) and examined FOBT variations among 483 PCPs. RESULTS: FOBT use remained unchanged during the study period. Of the 215,322 beneficiaries, 11% received at least one FOBT in 1998 and 11% in 1999; 18% had at least one test during the 2-year period, but only 4% had a test during both years. Caucasians and females had the highest FOBT rates. Although FOBT rates among PCPs ranged from 0 to 71%, only 19% of the practice rates exceeded 10%. CONCLUSIONS: Few beneficiaries obtain annual FOBT and little change in rates has occurred since Medicare reimbursement began. Although FOBT rates vary widely between PCPs, most either do not provide FOBT or do not bill Medicare for FOBT. The FOBT claims rate is much lower than reported in patient surveys and may indicate that Medicare should reexamine its reimbursement policy.

Direct observation of counseling on colorectal cancer in rural primary care practices.

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Direct observation of smoking cessation activities in primary care practice.

OBJECTIVE: Our goals were to determine how often family physicians incorporate smoking cessation efforts into routine office visits and to examine the effect of patient, physician, and office characteristics on the frequency of these efforts. STUDY DESIGN: Data was gathered using direct observation of physician-patient encounters, a survey of physicians, and an on-site examination of office systems for supporting smoking cessation. POPULATION: We included patients seen for routine office visits in 38 primary care physician practices. OUTCOMES MEASURED: The frequency of tobacco discussions among all patients, the extent of these discussions among smokers, and the presence of tobacco-related systems and policies in physicians' offices were measured. RESULTS: Tobacco was discussed during 633 of 2963 encounters (21%; range among practices = 0%-90%). Discussion of tobacco was more common in the 58% of practices that had standard forms for recording smoking status (26% vs 16%; P=.01). Tobacco discussions were more common during new patient visits but occurred less often with older patients and among physicians in practice more than 10 years. Of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Although 68% of offices had smoking cessation materials for patients, few recorded tobacco use in the "vital signs" section of the patient history or assigned smoking-related tasks to nonphysician personnel. CONCLUSIONS: Smoking cessation practices vary widely in primary care offices. Strategies are needed to assist physicians with incorporating systematic approaches to maximize smoking cessation rates.

Curriculum assessment for prevention topics and the population perspective.

BACKGROUND: According to the Association of American Medical College's (AAMC) Senior Questionnaire, medical students spend an inadequate amount of time learning about health promotion, disease prevention, and the population health perspective. OBJECTIVE: Determine the health promotion/disease prevention (HPDP) content of the medical school curriculum at the University of Kansas School of Medicine, using an inventory of knowledge and skills in HPDP and using physician education objectives from Healthy People 2000. METHODS: A 121-item survey to evaluate curriculum content was developed. All course directors evaluated their course by using this instrument. An average of three medical students used this instrument to assess each curriculum lecture and every clinical clerkship day in the required medical school curriculum. A teaching session was defined as spending a minimum of 3-5 minutes teaching an HPDP topic. RESULTS: Of 21 required courses in the medical school curriculum, 11 accounted for the 393 teaching sessions in HPDP. Seventy-five percent (293 sessions) of these dealt with clinical prevention. Quantitative methods received 40 sessions, whereas the health services organization and delivery and the community dimensions of medical practice received 37 and 23 sessions, respectively. Course directors and students disagreed significantly in which HPDP topics were taught in the curriculum. CONCLUSIONS: Clinical prevention was fairly well covered in the medical school curriculum. Quantitative methods, health services organization and delivery, and community dimensions of medical practice were poorly covered. This assessment was used to substantially improve the curriculum. To track and improve curriculum content in all courses, course directors need to know more precise details about the content of their courses, so this detail can be used to better evaluate the overall curriculum.

Warfarin for stroke prevention in octogenarians with atrial fibrillation.

The authors examined warfarin use in elderly patients with atrial fibrillation. Medical records were abstracted from a random sample of Medicare beneficiaries with atrial fibrillation who were discharged from Kansas hospitals. Data were analyzed for warfarin and aspirin use and risk factors for stroke or bleeding in patients 65-79 years of age or 80 years and older. Stroke risk factors other than age and atrial fibrillation were seen in 98% of 142 patients less than 80 years of age and 100% of 141 octogenarians. Warfarin use was similar in the younger and older age groups (50% vs. 45%, respectively; p = ns) and was not associated with the number of stroke or bleeding risk factors. Compared to patients less than 80 years of age, octogenarians were less likely to receive aspirin (38% vs. 27%, respectively; p < 0.05). Anticoagulation rates for high-risk patients with atrial fibrillation were low and poorly explained by stroke or bleeding risks.

Multistate utilization, processes, and outcomes of carotid endarterectomy.

OBJECTIVES: The purpose of this study was to describe variation in utilization, care processes, and outcomes for carotid endarterectomy (CEA) procedures in 10 states. METHODS: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between June 1, 1995, and May 31, 1996, in 10 different states to determine indications, care processes, and outcomes. This study also included medical record review of hospital readmissions within 30 days of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary files. RESULTS: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 10,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined event rates (CEA alone) by surgical indication were 7.7% for stroke (n = 1037), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific symptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combined event rates (CEA alone) among states ranged from 4.1% to 7.7% with the event rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multivariate analysis (correcting for indication), the use of preoperative antiplatelet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), and patch angioplasty (OR, 0.73) was significantly associated with lower combined event rates. There were significant differences among states in the use of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplasty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) and CEA combined with coronary artery bypass grafting (n = 236) were 6.3% and 17.4%, respectively. CONCLUSIONS: The striking variation among states suggests that there is room for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and adopt protocols that include the routine administration of antiplatelet agents preoperatively, the use of heparin intraoperatively, and patch angioplasty of the endarterectomy site.

Factors influencing infant visits to emergency departments.

OBJECTIVES: To follow the 1995 birth cohort of infants, born in the State of Missouri, through their first birthday to: 1) examine their rates of visits to emergency departments (EDs), 2) identify predictors of any ED visit, 3) examine rates of nonurgent ED visits, and 4) identify predictors of nonurgent visits. METHODS: This was a retrospective population cohort study. Using deterministic linkage procedures, 2 databases at the Missouri Department of Health (DOH; (the patient abstract database and the birth registry database) were linked by DOH personnel. International Classification of Diseases, Ninth Revision-Clinical Modification codes for ED visits were classified as emergent, urgent, or nonurgent by 2 researchers. Eight newborn characteristics were chosen for analysis. Negative binomial regression was used to examine the rates and predictors of both total and nonurgent ED visits. RESULTS: There were 935 total ED visits and 153 nonurgent ED visits per 1000 infant years. The average number of visits was.94, with 59% of infants having no visits, 21% having 1 ED visit, and 20% having 2 or more visits. Factors associated with increases in both total and nonurgent ED visits were Medicaid, self-pay, black race, rural region, presence of birth defects, and a nursery stay of >2 days. Significant interactions were found between Medicaid and race and Medicaid and rural regions on rates of ED use and nonurgent use. The highest rate of ED use, 1.8 per person year, was seen in white, rural infants on Medicaid, and the lowest rate (.4 per person year) was seen in urban white infants not on Medicaid. The highest rates of nonurgent use,.3 per person year, were among urban and rural Medicaid infants of both races and among black infants on commercial insurance. The lowest nonurgent rate,.04 per person year, was seen in white urban infants on commercial insurance. CONCLUSION: Infants in the State of Missouri have high rates of ED visits. Nonurgent visits are only a small portion of ED visits and cannot explain large variations in ED usage. Increased ED use by Medicaid patients may reflect continuing difficulties in accessing primary care.

Optimizing beta-blocker use after myocardial infarction.

Although beta-adrenergic blockers can significantly reduce mortality after a myocardial infarction, these agents are prescribed to only a minority of patients. Underutilization of beta blockers may be attributed, in part, to fear of adverse effects, especially in the elderly and in patients with concomitant disorders such as diabetes or heart failure. However, studies have shown that such patients are precisely the ones who derive the greatest benefit from beta blockade. Advancing age or the presence of potentially complicating disease states is usually not a justification for withholding beta-blocker therapy. With use of cardioselective agents and through careful dosing and monitoring, the benefits of beta blockers after myocardial infarction far outweigh the potential risks in most patients.

Impact of quality improvement activities on care for acute myocardial infarction.

OBJECTIVE: To examine the relationship between quality improvement activities reported to a peer review organization (PRO) and improvements in quality of care for patients with acute myocardial infarction (AMI). DESIGN: Time-series, comparative study of changes in care for AMI patients from 1992 to 1995 in hospitals reporting self-measurement or system changes compared to all other hospitals in the state. SETTING: One-hundred and seventeen acute care hospitals in Iowa. STUDY PARTICIPANTS: Patients hospitalized with a principal diagnosis of AMI. INTERVENTIONS: Each hospital was given hospital-specific performance data, statewide aggregate data, and peer comparisons and was asked to provide the PRO with a plan to improve care for AMI patients. MEASUREMENTS: Chart audits were performed before and after the intervention. Quality of care was based on eight explicit process measures of the quality of AMI care (quality indicators). RESULTS: Statewide, quality of care improved on five out of eight quality indicators. Of the 117 hospitals, 44 (38%) reported that they had implemented their own measurement activities or systematic improvements. These 44 hospitals showed significantly greater improvements than the other hospitals in use of aspirin during the hospitalization, recommendations for aspirin at discharge, and prescriptions for beta blockers at discharge. CONCLUSIONS: While quality of care for AMI patients throughout Iowa is improving, the pace of improvement is greatest in hospitals reporting that they are measuring their own performance or implementing systematic changes in care processes. Continued efforts to encourage hospitals to implement these types of improvement activities are warranted.

Improving the outcomes of carotid endarterectomy: results of a statewide quality improvement project.

OBJECTIVE: The purpose of this study was to establish the statewide outcomes for carotid endarterectomy (CEA) and to facilitate improvement in outcomes through feedback, peer discussion, and ongoing process and outcome measurement. METHODS: The Medicare Part A claims files were used to identify all Medicare patients undergoing CEA in Iowa during two 12-month time periods (January 1994-December 1994 and June 1995-May 1996). Medical record abstraction was used to obtain surgical indications, perioperative care process, and outcome information. Confidential reports were provided to each hospital (N = 30) where the procedure was performed. Surgeons performing the procedure (N = 79) were invited to meetings to discuss care process variation and outcomes. Voluntary participation was solicited in a standardized program of ongoing hospital-based data collection of CEA process and outcome data. RESULTS: The statewide combined stroke or mortality rate decreased from 7.8% in 1994 to 4.0% in the 1995 to 1996 time period (P <.001). Fourteen hospitals, accounting for 74% of the statewide cases, participated in ongoing data collection. The combined stroke or mortality rate in these hospitals decreased significantly (P <.05) over time from 6.5% (1994) to 3.7% (1995-1996) to 1.8% (June 1997-May 1998). The use of intraoperative assessment of the operative site (20% in 1994, 46% in 1997-1998) and patch angioplasty (14% in 1994, 30% in 1997-1998) increased significantly during this time in the participating hospitals. CONCLUSIONS: Confidential feedback of outcome and process data for CEA may lead to change in perioperative care processes and improved outcomes. Standardized community-based outcome analysis should become routine for CEA to ensure that optimum results are being achieved.

Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.

CONTEXT: Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish. OBJECTIVE: To improve the quality of care for Medicare patients with acute myocardial infarction. DESIGN: Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples. SETTING: All acute care hospitals in the United States. PATIENTS: Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995. Indicator comparisons were made with a random sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 1995. Mortality comparisons involved all Medicare patients nationwide with inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996. INTERVENTION: Data feedback by peer review organizations. MAIN OUTCOME MEASURES: Quality indicators derived from clinical practice guidelines, length of stay, and mortality. RESULTS: Performance on all quality indicators improved significantly in the 4 pilot states. Administration of aspirin during hospitalization in patients without contraindications improved from 84% to 90% (P< .001), and prescription of beta-blockers at discharge improved from 47% to 68% (P < .001). Mortality at 30 days decreased from 18.9% to 17.1% (P = .005) and at 1 year from 32.3% to 29.6% (P < .001). These improvements in quality occurred during a period when median length of stay decreased from 8 days to 6 days. Performance on all quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were statistically significant for aspirin use at discharge (P < .001), beta-blocker use (P < .001), and smoking cessation counseling (P = .02). Postinfarction mortality was not significantly different between the pilot states and the rest of the nation during the baseline period, although it was slightly but significantly better in the pilot states during the follow-up period (absolute mortality difference at 1 year, 0.9%; P = .004). CONCLUSIONS: The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.

Use and effectiveness of intravenous heparin therapy for treatment of acute myocardial infarction in the elderly.

OBJECTIVES: We sought to determine the use and association with 30-day mortality of intravenous heparin for the treatment of acute myocardial infarction in elderly patients not treated with a reperfusion strategy and without contraindications to anticoagulation. BACKGROUND: The benefit of using full-dose intravenous heparin for the treatment of acute myocardial infarction in the elderly is not known. METHODS: We conducted a retrospective cohort study using hospital medical records of all Medicare beneficiaries admitted to the hospital with an acute myocardial infarction in Alabama, Connecticut, Iowa and Wisconsin from June 1992 through February 1993. RESULTS: Among the 6,935 patients > or = 65 years old who had no absolute chart-documented contraindications to heparin, 3,227 (47%) received early full-dose intravenous heparin therapy. After adjustment for baseline differences in demographic, clinical and treatment factors between patients with and without heparin, the use of heparin (odds ratio 1.02, 95% confidence interval 0.87 to 1.18) was not associated with a significantly better 30-day mortality rate. CONCLUSIONS: Although intravenous heparin was commonly used for treatment of acute myocardial infarction in the elderly, it was not associated with an improved 30-day mortality rate. Although the findings of this observational study must be interpreted with care, they lead us to question whether the prevalent use of intravenous heparin has therapeutic effectiveness in this population.

Quality improvement at the national level. Lessons from the Cooperative Cardiovascular Project.

Most quality improvement projects address care delivered in one service of a hospital, such as the operating suite or the obstetrics service. Some projects are collaborative efforts involving groups of hospitals with similar interests. Few projects attempt to change care on a population basis (i.e., involving all providers in entire states or the nation as a whole.) The Cooperative Cardiovascular Project (CCP), sponsored by the Health Care Financing Administration, is attempting to improve care for all Medicare patients suffering from acute myocardial infarctions nation-wide. The CCP has been active since 1993 and, in a pilot project, has demonstrated that care can be improved on a population basis (i.e., in four entire states). This article explores the lessons learned from the CCP pilot and from the evolving CCP national experience.

Validation of a clinical prediction rule for left ventricular ejection fraction after myocardial infarction in patients > or = 65 years old.

We sought to validate a previously described clinical prediction rule for classifying left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI). As part of the Connecticut cohort of the Cooperative Cardiovascular Project (CCP) pilot study, we identified 3,093 Medicare patients who had been admitted to hospitals throughout Connecticut with an AMI in 1992 and 1993. Retrospective chart review and detailed electrocardiogram interpretation were performed. Of the 1,891 patients with an interpretable EF, 1,378 (73%) had > or = 1 of the rule's exclusion criteria. Of the remaining 513 patients, the clinical prediction rule had a positive predictive value of 89% (i.e., 456 of 513 patients had an EF > or = 40%). In a multivariate model, presentation > 6 hours after the onset of chest pain, a history of bypass surgery, and diabetes mellitus were associated with patients in whom the rule did not correctly predict an EF > or = 40%. Excluding patients with these characteristics from the rule increased the positive predictive value from 89% to 93% and excluded an additional 239 patients. The EF could not be predicted among the patients who did not meet the rule's criteria. In conclusion, a previously published clinical prediction rule for the classification of the EF in patients after an AMI correctly classified 8 of every 9 eligible elderly patients as having an EF > or = 40%. Thus, while not performing as well as it did in the original study, our findings support the use of this rule in providing clinicians with an objective method for estimating an EF > or = 40% in a specific subset of elderly patients.