Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty.

BACKGROUND: Little is known about the variation in complication rates among U.S. hospitals that perform elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures. The purpose of this study was to use National Quality Forum (NQF)-endorsed hospital-level risk-standardized complication rates to describe variations in, and disparities related to, hospital quality for elective primary THA and TKA procedures performed in U.S. hospitals. METHODS: We conducted a cross-sectional analysis of national Medicare Fee-for-Service data. The study cohort included 878,098 Medicare fee-for-service beneficiaries, sixty-five years or older, who underwent elective THA or TKA from 2008 to 2010 at 3479 hospitals. Both medical and surgical complications were included in the composite measure. Hospital-specific complication rates were calculated from Medicare claims with use of hierarchical logistic regression to account for patient clustering and were risk-adjusted for age, sex, and patient comorbidities. We determined whether hospitals with higher proportions of Medicaid patients and black patients had higher risk-standardized complication rates. RESULTS: The crude rate of measured complications was 3.6%. The most common complications were pneumonia (0.86%), pulmonary embolism (0.75%), and periprosthetic joint infection or wound infection (0.67%). The median risk-standardized complication rate was 3.6% (range, 1.8% to 9.0%). Among hospitals with at least twenty-five THA and TKA patients in the study cohort, 103 (3.6%) were better and seventy-five (2.6%) were worse than expected. Hospitals with the highest proportion of Medicaid patients had slightly higher but similar risk-standardized complication rates (median, 3.6%; range, 2.0% to 7.1%) compared with hospitals in the lowest decile (3.4%; 1.7% to 6.2%). Findings were similar for the analysis involving the proportion of black patients. CONCLUSIONS: There was more than a fourfold difference in risk-standardized complication rates across U.S. hospitals in which elective THA and TKA are performed. Although hospitals with higher proportions of Medicaid and black patients had rates similar to those of hospitals with lower proportions, there is a continued need to monitor for disparities in outcomes. These findings suggest there are opportunities for quality improvement among hospitals in which elective THA and TKA procedures are performed.

Regional associations between Medicare Advantage penetration and administrative claims-based measures of hospital outcomes.

BACKGROUND: Risk-standardized measures of hospital outcomes reported by the Centers for Medicare and Medicaid Services include Medicare fee-for-service (FFS) patients and exclude Medicare Advantage (MA) patients due to data availability. MA penetration varies greatly nationwide and seems to be associated with increased FFS population risk. Whether variation in MA penetration affects the performance on the Centers for Medicare and Medicaid Service measures is unknown. OBJECTIVE: To determine whether the MA penetration rate is associated with outcomes measures based on FFS patients. RESEARCH DESIGN: In this retrospective study, 2008 MA penetration was estimated at the Hospital Referral Region (HRR) level. Risk-standardized mortality rates and risk-standardized readmission rates for heart failure, acute myocardial infarction, and pneumonia from 2006 to 2008 were estimated among HRRs, along with several markers of FFS population risk. Weighted linear regression was used to test the association between each of these variables and MA penetration among HRRs. RESULTS: Among 304 HRRs, MA penetration varied greatly (median, 17.0%; range, 2.1%-56.6%). Although MA penetration was significantly (P<0.05) associated with 5 of the 6 markers of FFS population risk, MA penetration was insignificantly (P≥0.05) associated with 5 of 6 hospital outcome measures. CONCLUSION: Risk-standardized mortality rates and risk-standardized readmission rates for heart failure, acute myocardial infarction, and pneumonia do not seem to differ systematically with MA penetration, lending support to the widespread use of these measures even in areas of high MA penetration.

Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction.

BACKGROUND: Substantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs), but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited. METHODS: Hospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with ≥25 HF or AMI patients, respectively. Weighted regression was used to quantify the relationship between RSRRs and SNF rates for each condition. RESULTS: Mean RSRR following HF admission among 4101 hospitals was 24.7%, and mean RSRR after AMI admission among 2453 hospitals was 19.9%. Hospital-level SNF rates ranged from 0% to 83.8% for HF and from 0% to 77.8% for AMI. No significant relationship between RSRR after HF and SNF rate was found in adjusted regression models (P=.15). RSRR after AMI increased by 0.03 percentage point for each 1 absolute percentage point increase in SNF rate in adjusted regression models (P=.001). Overall, HF and AMI SNF rates explained <1% and 4% of the variation for their respective RSRRs. CONCLUSION: SNF rates after HF or AMI hospitalization vary considerably across hospitals, but explain little of the variation in 30-day all-cause readmission rates for these conditions.

National performance on door-in to door-out time among patients transferred for primary percutaneous coronary intervention.

BACKGROUND: Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for percutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time (ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services. METHODS: We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model. RESULTS: Among 13,776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except >75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P < .001). CONCLUSION: Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.

Improvements in door-to-balloon time in the United States, 2005 to 2010.

BACKGROUND: Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. METHODS AND RESULTS: This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: patients >75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes). CONCLUSION: National progress has been achieved in the timeliness of treatment of patients with ST-segment-elevation myocardial infarction who undergo primary percutaneous coronary intervention.

An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients.

BACKGROUND: Outcome measures for patients hospitalized with pneumonia may complement process measures in characterizing quality of care. We sought to develop and validate a hierarchical regression model using Medicare claims data that produces hospital-level, risk-standardized 30-day mortality rates useful for public reporting for patients hospitalized with pneumonia. METHODOLOGY/PRINCIPAL FINDINGS: Retrospective study of fee-for-service Medicare beneficiaries age 66 years and older with a principal discharge diagnosis of pneumonia. Candidate risk-adjustment variables included patient demographics, administrative diagnosis codes from the index hospitalization, and all inpatient and outpatient encounters from the year before admission. The model derivation cohort included 224,608 pneumonia cases admitted to 4,664 hospitals in 2000, and validation cohorts included cases from each of years 1998-2003. We compared model-derived state-level standardized mortality estimates with medical record-derived state-level standardized mortality estimates using data from the Medicare National Pneumonia Project on 50,858 patients hospitalized from 1998-2001. The final model included 31 variables and had an area under the Receiver Operating Characteristic curve of 0.72. In each administrative claims validation cohort, model fit was similar to the derivation cohort. The distribution of standardized mortality rates among hospitals ranged from 13.0% to 23.7%, with 25(th), 50(th), and 75(th) percentiles of 16.5%, 17.4%, and 18.3%, respectively. Comparing model-derived risk-standardized state mortality rates with medical record-derived estimates, the correlation coefficient was 0.86 (Standard Error = 0.032). CONCLUSIONS/SIGNIFICANCE: An administrative claims-based model for profiling hospitals for pneumonia mortality performs consistently over several years and produces hospital estimates close to those using a medical record model.

An administrative claims measure suitable for profiling hospital performance based on 30-day all-cause readmission rates among patients with acute myocardial infarction.

BACKGROUND: National attention has increasingly focused on readmission as a target for quality improvement. We present the development and validation of a model approved by the National Quality Forum and used by the Centers for Medicare & Medicaid Services for hospital-level public reporting of risk-standardized readmission rates for patients discharged from the hospital after an acute myocardial infarction. METHODS AND RESULTS: We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with acute myocardial infarction. The model was derived using Medicare claims data for a 2006 cohort and validated using claims and medical record data. The unadjusted readmission rate was 18.9%. The final model included 31 variables and had discrimination ranging from 8% observed 30-day readmission rate in the lowest predictive decile to 32% in the highest decile and a C statistic of 0.63. The 25th and 75th percentiles of the risk-standardized readmission rates across 3890 hospitals were 18.6% and 19.1%, with fifth and 95th percentiles of 18.0% and 19.9%, respectively. The odds of all-cause readmission for a hospital 1 SD above average were 1.35 times that of a hospital 1 SD below average. Hospital-level adjusted readmission rates developed using the claims model were similar to rates produced for the same cohort using a medical record model (correlation, 0.98; median difference, 0.02 percentage points). CONCLUSIONS: This claims-based model of hospital risk-standardized readmission rates for patients with acute myocardial infarction produces estimates that are excellent surrogates for those produced from a medical record model.

National patterns of risk-standardized mortality and readmission for acute myocardial infarction and heart failure. Update on publicly reported outcomes measures based on the 2010 release.

BACKGROUND: Patient outcomes provide a critical perspective on quality of care. The Centers for Medicare and Medicaid Services (CMS) is publicly reporting hospital 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) for patients hospitalized with acute myocardial infarction (AMI) and heart failure (HF). We provide a national perspective on hospital performance for the 2010 release of these measures. METHODS AND RESULTS: The hospital RSMRs and RSRRs are calculated from Medicare claims data for fee-for-service Medicare beneficiaries, 65 years or older, hospitalized with AMI or HF between July 1, 2006, and June 30, 2009. The rates are calculated using hierarchical logistic modeling to account for patient clustering, and are risk-adjusted for age, sex, and patient comorbidities. The median RSMR for AMI was 16.0% and for HF was 10.8%. Both measures had a wide range of hospital performance with an absolute 5.2% difference between hospitals in the 5th versus 95th percentile for AMI and 5.0% for HF. The median RSRR for AMI was 19.9% and for HF was 24.5% (3.9% range for 5th to 95th percentile for AMI, 6.7% for HF). Distinct regional patterns were evident for both measures and both conditions. CONCLUSIONS: High RSRRs persist for AMI and HF and clinically meaningful variation exists for RSMRs and RSRRs for both conditions. Our results suggest continued opportunities for improvement in patient outcomes for HF and AMI.

The performance of US hospitals as reflected in risk-standardized 30-day mortality and readmission rates for medicare beneficiaries with pneumonia.

BACKGROUND: Pneumonia is a leading cause of hospitalization and death in the elderly, and remains the subject of both local and national quality improvement efforts. OBJECTIVE: To describe patterns of hospital and regional performance in the outcomes of elderly patients with pneumonia. DESIGN: Cross-sectional study using hospital and outpatient Medicare claims between 2006 and 2009. SETTING: A total of 4,813 nonfederal acute care hospitals in the United States and its organized territories. PATIENTS: Hospitalized fee-for-service Medicare beneficiaries age 65 years and older who received a principal diagnosis of pneumonia. INTERVENTION: None. MEASUREMENTS: Hospital and regional level risk-standardized 30-day mortality and readmission rates. RESULTS: Of the 1,118,583 patients included in the mortality analysis 129,444 (11.6%) died within 30 days of hospital admission. The median (Q1, Q3) hospital 30-day risk-standardized mortality rate for patients with pneumonia was 11.1% (10.0%, 12.3%), and despite controlling for differences in case mix, ranged from 6.7% to 20.9%. Among the 1,161,817 patients included in the readmission analysis 212,638 (18.3%) were readmitted within 30 days of hospital discharge. The median (Q1, Q3) 30-day risk-standardized readmission rate was 18.2% (17.2%, 19.2%) and ranged from 13.6% to 26.7%. Risk-standardized mortality rates varied across hospital referral regions from a high of 14.9% to a low of 8.7%. Risk-standardized readmission rates varied across hospital referral regions from a high of 22.2% to a low of 15%. CONCLUSIONS: Risk-standardized 30-day mortality and, to a lesser extent, readmission rates for patients with pneumonia vary substantially across hospitals and regions and may present opportunities for quality improvement, especially at low performing institutions and areas.

Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission.

BACKGROUND: In 2009, the Centers for Medicare & Medicaid Services is publicly reporting hospital-level risk-standardized 30-day mortality and readmission rates after acute myocardial infarction (AMI) and heart failure (HF). We provide patterns of hospital performance, based on these measures. METHODS AND RESULTS: We calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of AMI or HF, discharged between July 2005 and June 2008. We compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions and hospital structural characteristics. The median 30-day mortality rate was 16.6% for AMI (range, 10.9% to 24.9%; 25th to 75th percentile, 15.8% to 17.4%; 10th to 90th percentile, 14.7% to 18.4%) and 11.1% for HF (range, 6.6% to 19.8%; 25th to 75th percentile, 10.3% to 12.0%; 10th to 90th percentile, 9.4% to 13.1%). The median 30-day readmission rate was 19.9% for AMI (range, 15.3% to 29.4%; 25th to 75th percentile, 19.5% to 20.4%; 10th to 90th percentile, 18.8% to 21.1%) and 24.4% for HF (range, 15.9% to 34.4%; 25th to 75th percentile, 23.4% to 25.6%; 10th to 90th percentile, 22.3% to 27.0%). We observed geographic differences in performance across the country. Although there were some differences in average performance by hospital characteristics, there were high and low hospital performers among all types of hospitals. CONCLUSIONS: In a recent 3-year period, 30-day risk-standardized mortality rates for AMI and HF varied among hospitals and across the country. The readmission rates were particularly high.

Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006.

CONTEXT: During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates. OBJECTIVE: To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI. DESIGN, SETTING, AND PATIENTS: Observational study using administrative data and a validated risk model to evaluate 3,195,672 discharges in 2,755,370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI. MAIN OUTCOME MEASURE: Hospital-specific 30-day all-cause RSMR. RESULTS: At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%. CONCLUSION: Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.

Reflections on becoming a specialty and its impact on global emergency medical care: our challenge for the future.

International emergency medicine development includes many activities. Among them are efforts to establish and support the development of the specialty of emergency medicine. In carrying out such activities, it is important for emergency physicians to be aware of the story of the establishment and development of the specialty of emergency medicine in the United States and to seek ways to support similar efforts in other countries. The benefits of specialty development toward improving emergency care globally are likely to be immense.

A study of the workforce in emergency medicine: 1999.

STUDY OBJECTIVE: We estimate the total number of physicians practicing clinical emergency medicine during a specified period, describe certain characteristics of those individuals to estimate the total number of full-time equivalents (FTEs) and the total number of individuals needed to staff those FTEs, and compare the data collected with those data collected in 1997. METHODS: Data were gathered from a survey of a random sample of 2,153 hospitals drawn from a population of 5,329 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, and the total number of physicians working during the period from June 6 to June 9, 1999. Demographic data on the individuals were also collected. RESULTS: A total of 940 hospitals responded (a 44% return rate). These hospitals reported that a total of 6,719 physicians were working during the specified period, or an average of 7.85 persons scheduled per institution. The physicians were scheduled for a total of 347,702 hours. The average standard for FTE was 40 clinical hours per week. This equates to 4,346 FTEs or 5.29 FTEs per institution. The ratio of persons to FTEs was 1.48:1. With regard to demographics, 83% of the physicians were men, and 82% were white. Their average age was 42.6 years. As for professional credentials, 42% were emergency medicine residency trained, and 58% were board certified in emergency medicine; 50% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 5,064 hospitals with EDs and given that the data indicate that there are 5.35 FTEs per ED, the total number of FTEs is projected to be 27,067 (SE=500). Given further that the data indicate a physician/FTE ratio of 1.47:1, we conclude that there are 39,746 persons (SE=806) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 31,797. When the 1999 data are compared with those collected in 1997, we note a statistically significant decline in the number of hospital EDs, from 5,126 in 1997 to 5,064 in 1999 (P =.02). The total number of emergency physicians remained the same over the 2-year period, whereas the number of FTEs per institution increased from 5.11 to 5.35. The physician/FTE ratio remained unchanged.