Is readmission to hospital an indicator of poor process of care for patients with heart failure?

BACKGROUND: Controversy exists about the appropriateness of using readmission as an indicator of the quality of care. A study was undertaken to measure the validity and predictive ability of readmission in this context. METHODS: An evaluation study was performed in patients discharged alive with heart failure from three Swiss academic medical centres. Process quality indicators were derived from evidence based guidelines for the management and treatment of heart failure. Readmissions were calculated from hospital administrative data. The predictive ability of readmissions was evaluated using bivariate and multivariate analyses, and validity by calculating sensitivity, specificity, positive and negative predictive value, using process indicators as the "gold standard". RESULTS: Of 1055 eligible patients discharged alive, 139 (13.2%) were readmitted within 30 days. The adjusted odds ratio (OR) for absence of measurement of left ventricular function was 0.70 (95% CI 0.45 to 1.08) for readmissions. In patients with left ventricular systolic dysfunction, three dose categories of angiotensin converting enzyme inhibitor were examined using ordinal logistic regression. The adjusted OR for these categories was 1.07 (95% CI 0.56 to 2.06) for readmissions. When using process indicators as the gold standard to assess the validity of readmissions, sensitivity ranged from 0.08 to 0.17 and specificity from 0.86 to 0.93. CONCLUSIONS: Readmission did not predict and was not a valid indicator of the quality of care for patients with heart failure admitted to three Swiss university hospitals.

Do reminder signs promote use of safety belts?

STUDY OBJECTIVE: To determine whether reminder signs placed at the exits to parking decks increase the rate of safety belt use. METHODS: The subjects in this study were drivers of automobiles with permits to park in campus decks at a major university. Volunteer observers were positioned near the exits of 5 parking decks around the campus. Rates of safety belt use were noted before and at 2 intervals after reminder signs were installed. RESULTS: A total of 6, 780 observations were collected. The baseline rate of safety belt use was 83%. Female drivers were significantly more likely to wear a safety belt than male drivers (85.3% versus 79.6%, P <.001). Safety belt use did not increase after the signs were installed (83.3% before versus 83.5% after, P =.86). CONCLUSION: Placing reminder signs at the exits to parking decks did not boost the rate of safety belt use at our institution. Other strategies are needed to achieve the National Highway Traffic Safety Administration's goal of increasing the overall rate of safety belt usage to 90% by the year 2005.

The "Sherman effect": decreased ambulatory care volumes in Atlanta during the 1996 Summer Olympic Games.

OBJECTIVE: To estimate the effect of the 1996 Atlanta Summer Olympic Games on visits to local ambulatory healthcare facilities. DESIGN: Comparison of median visit rates by time period, obtained from retrospective review of administrative data. SETTING: The emergency department of the designated athletes' hospital, the public hospital's adult emergency department and adult walk-in clinics, and the adult and paediatric outpatient facilities of a large health maintenance organisation. PATIENTS: All 132,826 visitors to the designated facilities during the study interval. MAIN OUTCOME MEASURE: Daily visit frequencies at each facility. Our informal observations had suggested that volumes were not as high as expected. RESULTS: In all but the athletes' designated hospital, there was a decrease in average volumes the week before the opening ceremonies, ranging from zero to 8.4% of baseline. Average daily volumes in these non-venue facilities varied from 3.2% above to 16.1% below baseline during the two weeks of the Games, but all experienced an increase in volumes the week after the closing ceremonies, ranging from 3.0% to 13.7% of baseline. CONCLUSION: Unlike the venue-related facility, community ambulatory care sites did not encounter a significant rise in volumes until after the closing ceremonies. Although confirmation from other events is needed, our data suggest that, in addition to increased preparedness for sudden volume surges, overtime staffing of local facilities during planned mass gatherings should occur not during, but immediately after, the event.

Hydroxyurea in two pregnant women with sickle cell anemia.

Hydroxyurea is classified as an S-phase antineoplastic agent (pregnancy category D). Two women became pregnant while taking hydroxyurea for sickle cell anemia and delivered live infants with no congenital anomalies. Although teratogenic effects of hydroxyurea were reported in animal studies, several case reports suggest the agent may have minimal teratogenic effects on the developing fetus. Fourteen cases of hydroxyurea therapy in pregnant patients with acute or chronic myelogenous leukemia, primary thrombocythemia, or sickle cell disease are reported in the literature. Three pregnancies were terminated by elective abortion; one woman developed eclampsia and delivered a phenotypically normal stillborn infant. All other patients delivered live, healthy infants without congenital anomalies. Further studies with larger numbers of patients receiving hydroxyurea during pregnancy, with longer follow-up of exposed children and more careful assessment of fetotoxic effects, are required before the agent can be promoted as safe in pregnancy.

Emergency department hypertension and regression to the mean.

STUDY OBJECTIVE: To evaluate the importance of regression to the mean in the assessment of asymptomatic hypertension in the emergency department. METHODS: This was an historical cohort study of patients in the adult ED of a large urban teaching hospital. THe main outcome was changed in diastolic blood pressure (DBP). Subjects were 195 consecutive hypertensive patients with two sets of vital signs. Patients with specified acute conditions potentially associated with abnormal blood pressure were excluded, as were patients given vasoactive medications. RESULTS: A statistical formula was used to predict the average blood pressure for hypertensive patients, using the observed mean and standard deviation of an all-patient sample. Given a threshold of 90 mm Hg, the expected mean DBP for hypertensive patients was 102.7 mm Hg, compared with an observed value of 104.5 mm Hg. Given an observed correlation coefficient of .73 between first and second measurements, a formula for regression to the mean predicted a spontaneous blood pressure decline of 7.2 mn Hg. A mean decline if 11.6 mm Hg was observed. The decline of 4.4 mm Hg more than expected among asymptomatic hypertensives was similar to the spontaneous decline of 3.7 mm Hg observed in the all-patient sample. CONCLUSION: Patients who present with asymptomatic hypertension in the ED on average experience a spontaneous decline in blood pressure after they arrive. Most of this effect can be explained by regression to the mean. A small amount of this drop may represent attenuation of an initial alerting reaction.

Supraclavicular subclavian vein catheterization: modified landmarks for needle insertion.

STUDY OBJECTIVE: Identification of reliable landmarks for supraclavicular subclavian vein catheterization that requires no patient manipulation and is easily located. PATIENT POPULATION: Thirty-five fresh human cadavers. DESIGN AND METHODS: Descriptive study of percutaneous guide wire placement into the subclavian vein using as a new landmark the junction of middle and medial thirds of the clavicle. The position of the guide wire was confirmed by palpation of the wire in the subclavian vein during autopsy. RESULTS: Successful placement of a guide wire into the subclavian vein occurred in 33 of 35 cadavers (94%) using the new landmark. CONCLUSION: The new landmark for supraclavicular subclavian vein catheterization is reliable, requires no patient manipulation, and is as successful as the standard landmarks.