COVID-19 inpatient care performance in the unified health system, São Paulo state, Brazil: an application of standardized mortality ratio for hospitals' comparisons : COVID-19 inpatient care performance in SUS, Brazil.

OBJECTIVE: To evaluate the variation in COVID-19 inpatient care mortality among hospitals reimbursed by the Unified Health System (SUS) in the first two years of the pandemic in São Paulo state and make performance comparisons within periods and over time. METHODS: Observational study based on secondary data from the Hospital Information System. The study universe consisted of 289,005 adult hospitalizations whose primary diagnosis was COVID-19 in five periods from 2020 to 2022. A multilevel regression model was applied, and the death predictive variables were sex, age, Charlson Index, obesity, type of admission, Brazilian Deprivation Index (BrazDep), the month of admission, and hospital size. Then, the total observed deaths and total deaths predicted by the model's fixed effect component were aggregated by each hospital, estimating the Standardized Mortality Ratio (SMR) in each period. Funnel plots with limits of two standard deviations were employed to classify hospitals by performance (higher-than-expected, as expected, and lower-than-expected) and determine whether there was a change in category over the periods. RESULTS: A positive association was observed between hospital mortality and size (number of beds). There was greater variation in the percentage of hospitals with as-expected performance (39.5 to 76.1%) and those with lower-than-expected performance (6.6 to 32.3%). The hospitals with higher-than-expected performance remained at around 30% of the total, except in the fifth period. In the first period, 64 hospitals (18.3%) had lower-than-expected performance, with standardized mortality ratios ranging from 1.2 to 4.4, while in the last period, only 23 (6.6%) hospitals were similarly classified, with ratios ranging from 1.3 to 2.8. A trend of homogenization and adjustment to expected performance was observed over time. CONCLUSION: Despite the study's limitations, the results suggest an improvement in the COVID-19 inpatient care performance of hospitals reimbursed by the SUS in São Paulo over the period studied, measured by the standardized mortality ratio for hospitalizations due to COVID-19. Moreover, the methodological approach adapted to the Brazilian context provides an applicable tool to follow-up hospital's performance in caring all or specific-cause hospitalizations, in regular or exceptional emergency situations.

Razão de mortalidade hospitalar padronizada: limites e potencialidades do indicador para a avaliação do desempenho hospitalar no Sistema Único de Saúde, Brasil / Hospital standardized mortality ratio: limits and potential of the indicator for assessing hospital performance in the Brazilian Unified National Health System / Razón de mortalidad hospitalaria estandarizada: límites y potencialidades del indicador para la evaluación del desempeño hospitalario en el Sistema Único de Salud, Brasil

Resumo: Análises comparativas, baseadas em indicadores de desempenho clínico, para monitorar a qualidade da assistência hospitalar vêm sendo realizadas há décadas em vários países, com destaque para a razão de mortalidade hospitalar padronizada (RMHP). No Brasil, ainda são escassos os estudos e a adoção de instrumentos metodológicos que permitam análises regulares do desempenho das instituições. O objetivo deste artigo foi explorar o uso da RMHP para a comparação do desempenho dos hospitais remunerados pelo Sistema Único de Saúde (SUS). O Sistema de Informações Hospitalares foi a fonte de dados sobre as internações de adultos realizadas no Brasil entre 2017 e 2019. A abordagem metodológica para estimar a RMHP foi adaptada aos dados disponíveis e incluiu as causas de internação (diagnóstico principal) responsáveis por 80% dos óbitos. O número de óbitos esperados foi estimado por um modelo de regressão logística que incluiu variáveis preditoras amplamente descritas na literatura. A análise foi realizada em duas etapas: (i) nível da internação e (ii) nível do hospital. O modelo final de ajuste de risco apresentou estatística C de 0,774, valor considerado adequado. Foi observada grande variação da RMHP, especialmente entre os hospitais com pior desempenho (1,54 a 6,77). Houve melhor desempenho dos hospitais privados em relação aos hospitais públicos. Apesar de limites nos dados disponíveis e desafios ainda vislumbrados para a sua utilização mais refinada, a RMHP é aplicável e tem potencial para se tornar um elemento importante na avaliação do desempenho hospitalar no SUS.

Abstract: Comparative analyses based on clinical performance indicators to monitor the quality of hospital care have been carried out for decades in several countries, most notably the hospital standardized mortality ratio (HSMR). In Brazil, studies and the adoption of methodological tools that allow regular analysis of the performance of institutions are still scarce. This study aimed to assess the use of HSMR to compare the performance of hospitals funded by the Brazilian Unified National Health System (SUS). The Hospital Information System was the source of data on adult hospitalizations in Brazil from 2017 to 2019. The methodological approach to estimate HSMR was adapted to the available data and included the causes of hospitalization (main diagnosis) responsible for 80% of deaths. The number of expected deaths was estimated using a logistic regression model that included predictor variables widely described in the literature. The analysis was conducted in two stages: (i) hospitalization level and (ii) hospital level. The final risk adjustment model showed a C-statistic of 0.774, which is considered adequate. The variation in HSMR was wide, especially among the worst-performing hospitals (1.54 to 6.77). Private hospitals performed better than public hospitals. Although the limits of the available data and the challenges still face its more refined use, HSMR is applicable and has the potential to become an important tool for assessing hospital performance in the SUS.

Resumen: Durante décadas se han realizado en varios países análisis comparativos basados en indicadores de desempeño clínico para monitorear la calidad de la atención hospitalaria, con énfasis en la razón de mortalidad hospitalaria estandarizada (RMHE). En Brasil, aún son escasos los estudios y la adopción de instrumentos metodológicos que permitan análisis regulares del desempeño de las instituciones. El objetivo fue explorar el uso de la RMHE para comparar el desempeño de los hospitales remunerados por el Sistema Único de Salud (SUS). El Sistema de Información Hospitalaria fue la fuente de datos sobre las hospitalizaciones de adultos realizadas en Brasil entre el 2017 y el 2019. El enfoque metodológico para estimar la RMHE se adaptó a los datos disponibles e incluyó las causas de hospitalización (diagnóstico principal) responsables del 80% de las muertes. El número de muertes esperadas se estimó mediante un modelo de regresión logística que incluyó variables predictoras ampliamente descritas en la literatura. El análisis se realizó en dos etapas: (i) nivel de la hospitalización y (ii) nivel del hospital. El modelo final de ajuste de riesgo presentó una estadística C de 0,774, valor considerado adecuado. Se observó una gran variación en la RMHE, especialmente entre los hospitales con peor desempeño (1,54 a 6,77). Hubo un mejor desempeño de los hospitales privados en comparación con los hospitales públicos. A pesar de las limitaciones de los datos disponibles y de los desafíos aún previstos para su uso más refinado, la RMHE es aplicable y tiene el potencial de convertirse en un elemento importante en la evaluación del desempeño hospitalario en el SUS.

International Perception of Perioperative Risk for Arthroplasty-Experience of the Colombian Health System.

BACKGROUND: Following a recent publication of the American Association of Hip and Knee Surgeons (AAHKS) which found that 95% of respondents address risk factors before surgery and the challenges in the ultimate access to care, the authors proposed an international collaboration in order to gain insight on how performance measures affect access to care as well as what medical and/or socioeconomic factors are considered obstacles to good outcomes from an international perspective. The aim of this study was to poll Colombia's arthroplasty surgeons regarding their approach to patients who have modifiable risk factors. METHODS: The survey used in the AAHKS study was adapted for use in the Colombian context and distributed to the members of the Colombian Society of Hip and Knee Surgeons (SOCCAR) via a collaborative format online, and it was completed by 109 out of 163 members, a response rate of 67%. RESULTS: Overall, 67% limit or restrict surgery in patients with specific modifiable risk factors. Those factors most likely to delay or restrict treatment were malnutrition/hypoalbuminemia (95.9%), poor diabetic control (89%), and active smoking (61.6%). Limited social support was considered a liability by 82.2% of surgeons. Over 80% of respondents decide based on personal experience or literature review. Low socioeconomic status was considered a factor for limiting access by 53.4% of polled surgeons. 91.8% believe some patient populations would benefit with better access to care if payment systems provided better risk adjustment. CONCLUSION: Only 67% of Colombian arthroplasty surgeons limit or restrict elective surgery in patients with modifiable risk factors, mainly considering malnutrition and poorly controlled diabetes as a cause for restriction, and half of the surgeons consider low socioeconomic status as a limitation to arthroplasty surgery. These findings contrast dramatically to the practice patterns of American AAHKS members.

Translation and Validation of the Boston Technical Performance Score in a Developing Country.

INTRODUCTION: The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. METHODS: The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. RESULTS: Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). CONCLUSION: TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.

Translation and Validation of the Boston Technical Performance Score in a Developing Country

Abstract Introduction: The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. Methods: The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. Results: Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). Conclusion: TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.

Impact of the COVID-19 pandemic on coronary artery bypass graft surgery in Brazil: A nationwide perspective.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has been a worldwide challenge, and efforts to "flatten the curve," including restrictions imposed by policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. The aim of this study is to evaluate the outcomes of coronary artery bypass graft (CABG) from 2008 to 2020 in the SUS and to assess the impacts of the COVID-19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS. METHODS: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures and death rates. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. RESULTS: We identified 281,760 CABG procedures performed from January 2008 to December 2020. The average number of procedures until the end of 2019 was of 22,104. During 2020 there was a 25% reduction CABG procedures, to 16,501. There was an increase in the national death rate caused by a statistical significant increase in death rates in Brazil's Southeast and Central-west regions. CONCLUSION: The COVID-19 pandemic remains a global challenge for Brazil's health care system. During the year of 2020 there was a reduction in access to CABG related to an increase in the number of COVID-19 cases. There was also an increase in the national CABG death rate.

A supervised clustering MCMC methodology for large categorical feature spaces.

There is a well-established tradition within the statistics literature that explores different techniques for reducing the dimensionality of large feature spaces. The problem is central to machine learning and it has been largely explored under the unsupervised learning paradigm. We introduce a supervised clustering methodology that capitalizes on a Metropolis Hastings algorithm to optimize the partition structure of a large categorical feature space tailored towards minimizing the test error of a learning algorithm. This is a general methodology that can be applied to any supervised learning problem with a large categorical feature space. We show the benefits of the algorithm by applying this methodology to the problem of risk adjustment in competitive health insurance markets. We use a large claims data set that records ICD-10 codes, a large categorical feature space. We aim at improving risk adjustment by clustering diagnostic codes into risk groups suitable for health expenditure prediction. We test the performance of our methodology against common alternatives using panel data from a representative sample of twenty three million citizens in Colombian Healthcare System. Our results outperform common alternatives and suggest that it has potential to improve risk adjustment.

The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population.

BACKGROUND: Medically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs. METHODS: Retrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed. RESULTS: 4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications. CONCLUSION: HFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.

Estimación del riesgo en cirugía cardíaca en el "mundo real": ArgenSCORE ajustado al centro / Cardiovascular Surgery Risk Assessment in the "Real World": ArgenSCORE Adjusted by Center

RESUMEN Introducción: El ArgenSCORE tiene una versión original (I) desarrollada en 1999 sobre una población con mortalidad del 8% y una versión II (recalibración del modelo en 2007) sobre una población con una mortalidad del 4%. Evaluamos en el registro CONAREC XVI la hipótesis de que el ArgenSCORE II podría estimar mejor el riesgo de mortalidad intrahospitalaria en los centros con baja mortalidad; en cambio, el ArgenSCORE I estimaría mejor la mortalidad en los centros con alta mortalidad. Material y métodos: Se analizaron 2548 pacientes de 44 centros del registro prospectivo y multicéntrico en cirugía cardíaca, CONAREC XVI. En cada centro se evaluó la mortalidad media observada (MO) y se calculó la mortalidad estimada media (ME) aplicando ambas versiones del ArgenSCORE. Se calculó la relación MO/ME de cada centro para los dos modelos y se evaluó si había diferencias significativas mediante el test Z. Resultados: La mortalidad intrahospitalaria del registro fue del 7,69%. El 75% de los centros (33/44) presentaban una mortalidad mayor del 6%. En centros con mortalidad menor del 6%, al aplicar el ArgenSCORE II, la relación MO/ME mostró valores cercanos a 1 y sin diferencias significativas. En centros con mortalidad mayor del 6%, el ArgenSCORE II subestima significativamente el riesgo. En cambio, cuando se aplica en estos centros el ArgenSCORE I, la relación MO/ME es cercana a 1 (sin diferencias significativas). Conclusiones: En centros con mortalidad menor del 6%, es recomendable utilizar el ArgenSCORE II-recalibrado; en centros con mortalidad mayor del 6%, tiene mejor desempeño el ArgenSCORE I-original.

ABSTRACT Background: The ArgenSCORE I was developed in 1999 on a population with 8% mortality. The ArgenSCORE II emerged after recalibrating the original model in 2007 on a validation population with 4% mortality. Using the CONAREC XVI registry, we evaluated the hypothesis that the ArgenSCORE II could better predict the risk of in-hospital mortality in centers with low mortality, whereas the ArgenSCORE I could better predict mortality in centers with high mortality. Methods: A total of 2548 patients from 44 centers of the prospective and multicenter cardiac surgery CONAREC XVI registry, were analyzed. Mean observed mortality (OM) and mean expected mortality (EM) were estimated applying both versions of the ArgenSCORE. The OM/EM ratio was calculated in each center for both models and the Z test was used to evaluate significant differences. Results: In-hospital mortality was 7.69% for the entire registry. In 75% of the centers (33/44) mortality was >6%. In centers with mortality <6%, the OM/EM ratio was close to 1 after applying the ArgenSCORE II, without significant differences. In centers with mortality >6%, the ArgenSCORE II significantly underestimated the risk. On the contrary, when the ArgenSCORE I was applied in these centers, the OM/EM ratio was close to 1, without significant differences. Conclusions: The recalibrated ArgenSCORE II is recommended in centers with mortality <6%, while in those with mortality >6% the original ArgenSCORE I has better performance.

Coronary artery bypass graft surgery in Brazil from 2008 to 2017.

BACKGROUND: Brazil is an upper middle-income country in South America with the world's sixth largest population. Despite great advances in health-care services and cardiac surgical care in both its public and private health systems, little is known on the volume, outcomes, and trends of coronary artery bypass grafting (CABG) in Brazil's public health system. OBJECTIVE: The aim of this study was to evaluate the outcome of CABG on the public health system from January 2008 to December 2017 through the database DATASUS. METHODS: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures, death rates, length of stay, and costs. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. The χ2 test was used to compare death rates. A p < .05 was considered statistically significant. RESULTS: We identified 226,697 CABG procedures performed from January 2008 to December 2017. The overall in-hospital mortality over the 10-year period was 5.7%. We observed statistically significant differences in death rates between the five Brazilian macro-regions. Death rates by state ranged from 2.6% to 13.1%. The national average mortality rate remained stable over the course of time. CONCLUSION: Over 10 years, a high volume of CABG was performed in the Brazilian Public Health System, with significant differences in mortality, number of procedures, and distribution of surgeries by region. Future databases involving all centers that perform CABG and carry out risk-adjusted analysis will help improve Brazilian results and enable policymakers to adopt appropriate health-care policies for greater transparency and accountability.

Surveillance for Hepatocellular Carcinoma: Does the Place Where Ultrasound Is Performed Impact Its Effectiveness?

BACKGROUND: Biannual ultrasound (US) is recommended as the clinical screening tool for hepatocellular carcinoma (HCC). The effectiveness of surveillance according to the place where US is performed has not been previously reported. AIMS: To compare the effectiveness of US performed in the center responsible for follow-up as opposed to US proceeding from centers other than that of follow-up. METHODS: This is a multicenter cohort study from Argentina. The last US was categorized as done in the same center or done in a different center from the institution of the patient's follow-up. Surveillance failure was defined as HCC diagnosis not meeting Barcelona Clinic Liver Cancer (BCLC) stages 0-A or when no nodules were observed at HCC diagnosis. RESULTS: From 533 patients with HCC, 62.4% were under routine surveillance with a surveillance failure of 38.8%. After adjusting for a propensity score matching, BCLC stage and lead-time survival bias, surveillance was associated with a significant survival benefit [HR of 0.51 (CI 0.38; 0.69)]. Among patients under routine surveillance (n = 345), last US was performed in the same center in 51.6% and in a different center in 48.4%. Similar rates of surveillance failure were observed between US done in the same or in a different center (32% vs. 26.3%; P = 0.25). Survival was not significantly different between both surveillance modalities [HR 0.79 (CI 0.53; 1.20)]. CONCLUSIONS: Routine surveillance for HCC in the daily practice improved survival either when performed in the same center or in a different center from that of patient's follow-up.

Improving Hospital Performance Rankings Using Discrete Patient Diagnoses for Risk Adjustment of Outcomes.

OBJECTIVE: To assess the changes in patient outcome prediction and hospital performance ranking when incorporating diagnoses as risk adjusters rather than comorbidity indices. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient Databases for New York State, 2005-2009. STUDY DESIGN: Conducted tree-based classification for mortality and readmission by incorporating discrete patient diagnoses as predictors, comparing with traditional comorbidity indices such as those used for Centers for Medicare and Medicaid Services (CMS) outcome models. PRINCIPAL FINDINGS: Diagnosis codes as predictors increased predictive accuracy 5.6 percent (95% CI: 4.5-6.9 percent) relative to CMS condition categories for heart failure 30-day mortality. Most other outcomes exhibited statistically significant accuracy gains and facility ranking shifts. Sensitivity analysis showed improvements even when predictors were limited to only the diagnoses included in CMS models. CONCLUSIONS: Discretizing patient severity information beyond the levels of traditional comorbidity indices improves patient outcome predictions and substantially shifts facility rankings.

Avaliação do desempenho do PIM-2 entre pacientes cardiopatas cirúrgicos e correlação dos resultados com RACHS-1 / Assessment of PIM-2 performance among surgical patients with heart disease and correlation of results with RACHS-1

RESUMO Objetivo: Avaliar o desempenho do Pediatric Index of Mortality (PIM) 2 e do Escore de Risco Ajustado para Cirurgia Cardíaca Congênita (RACHS) no pós-operatório de cardiopatas congênitos. Métodos: Estudo transversal retrospectivo. Foram coletados dados de prontuário para gerar os escores e predições com as técnicas preconizadas, os dados demográficos e os desfechos. Para estatística, utilizaram-se o teste de Mann-Whitney, o teste de Hosmer-Lemeshow, a taxa de mortalidade padronizada, a área sobre a curva COR, qui quadrado, regressão de Poisson com variância robusta e teste de Spearman. Resultados: Foram avaliados 263 pacientes, e 72 foram a óbito (27,4%). Estes apresentaram valores de PIM-2 significativamente maiores que os sobreviventes (p < 0,001). Na classificação RACHS-1, a mortalidade foi progressivamente maior, de acordo com a complexidade do procedimento, com aumento de 3,24 vezes na comparação entre os grupos 6 e 2. A área abaixo da curva COR para o PIM-2 foi 0,81 (IC95% 0,75 - 0,87) e, para RACHS-1, de 0,70 (IC95% 0,63 - 0,77). A RACHS apresentou melhor poder de calibração na amostra analisada. Foi encontrada correlação significativamente positiva entre os resultados de ambos os escores (rs = 0,532; p < 0,001). Conclusão: A RACHS apresentou bom poder de calibração, e RACHS-1 e PIM-2 demonstraram bom desempenho quanto à capacidade de discriminação entre sobreviventes e não sobreviventes. Ainda, foi encontrada correlação positiva entre os resultados dos dois escores de risco.

ABSTRACT Objective: To assess the performance of the Pediatric Index of Mortality (PIM) 2 and the Risk Adjustment for Congenital Heart Surgery (RACHS) in the postoperative period of congenital heart disease patients. Methods: Retrospective cross-sectional study. Data were collected from patient records to generate the scores and predictions using recommended techniques, demographic data and outcomes. The Mann-Whitney test, Hosmer-Lemeshow test, standardized mortality rate, area under the receiver operating characteristic (ROC) curve, chi square test, Poisson regression with robust variance and Spearman's test were used for statistical analysis. Results: A total of 263 patients were evaluated, and 72 died (27.4%). These patients presented significantly higher PIM-2 values than survivors (p < 0.001). In the RACHS-1 classification, mortality was progressively higher according to the complexity of the procedure, with a 3.24-fold increase in the comparison between groups 6 and 2. The area under the ROC curve for PIM-2 was 0.81 (95%CI 0.75 - 0.87), while for RACHS-1, it was 0.70 (95%CI 0.63 - 0.77). The RACHS presented better calibration power in the sample analyzed. A significantly positive correlation was found between the results of both scores (rs = 0.532; p < 0.001). Conclusion: RACHS presented good calibration power, and RACHS-1 and PIM-2 demonstrated good performance with regard to their discriminating capacities between survivors and non-survivors. Moreover, a positive correlation was found between the results of the two risk scores.

Surgical Interventions in Infants Born Preterm with Congenital Heart Defects: An Analysis of the Kids' Inpatient Database.

OBJECTIVE: To evaluate short-term outcomes in infants born preterm with congenital heart defects (CHDs) and the factors associated with surgery, survival, and length of hospitalization in this population. STUDY DESIGN: We analyzed data from infants born preterm (gestational age <37 weeks) enrolled in the multicenter Kids' Inpatient Database of the Healthcare Cost and Utilization Project who were admitted to the hospital within 30 days after birth. Infants with atrial septal defects were excluded. RESULTS: Of 1 429 762 enrolled infants born preterm, 27 434 (2.0%) with CHDs were included. Overall survival to discharge was 90.5%; 74.0% among infants with critical CHDs and 45.7% among infants with hypoplastic left heart syndrome. Cardiac surgeries were performed in 12.2% of all infants born preterm. Rates of surgical intervention for infants with critical CHDs were lower for very low birth weight (≤1.5 kg) vs larger infants >1.5 kg (27% vs 44%), and only 6.3% of infants born with very low birth weight underwent surgeries in Risk-adjustment for Congenital Heart Surgery categories 4 or greater. Greater birth weight, left-sided lesions, care at children's hospitals, and absence of trisomies were associated with a greater likelihood of surgery. Birth weight <2 kg, nonwhite race, trisomy syndromes, prematurity-related morbidities, and Risk-adjustment for Congenital Heart Surgery category 4 or greater were independent predictors of mortality. Birth weight <2 kg, Risk-adjustment for Congenital Heart Surgery category, morbidities, and sidedness of lesion predicted length of stay. CONCLUSIONS: The high survival rates of infants born preterm with CHDs suggests that a cautiously optimistic approach to surgery may be warranted in all but the most immature infants with the greatest-risk conditions.

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

OBJECTIVES: To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models. STUDY DESIGN: We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy. RESULTS: For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals. CONCLUSIONS: We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.

Severity of illness index for surgical departments in a Cuban hospital: a revalidation study. / Índice de gravedad para servicios quirúrgicos en un hospital cubano: estudio de revalidación.

INTRODUCTION: In the context of the evaluation of hospital services, the incorporation of severity indices allows an essential control variable for performance comparisons in time and space through risk adjustment. The severity index for surgical services was developed in 1999 and validated as a general index for surgical services. Sixteen years later the hospital context is different in many ways and a revalidation was considered necessary to guarantee its current usefulness. OBJECTIVE: To evaluate the validity and reliability of the surgical services severity index to warrant its reasonable use under current conditions. METHODS: A descriptive study was carried out in the General Surgery service of the "Hermanos Ameijeiras" Clinical Surgical Hospital of Havana, Cuba during the second half of 2010. We reviewed the medical records of 511 patients discharged from this service. Items were the same as the original index as were their weighted values. Conceptual or construct validity, criterion validity and inter-rater reliability as well as internal consistency of the proposed index were evaluated. RESULTS: Construct validity was expressed as a significant association between the value of the severity index for surgical services and discharge status. A significant association was also found, although weak, with length of hospital stay. Criterion validity was demonstrated through the correlations between the severity index for surgical services and other similar indices. Regarding criterion validity, the Horn index showed a correlation of 0.722 (95% CI: 0.677-0.761) with our index. With the POSSUM score, correlation was 0.454 (95% CI: 0.388-0.514) with mortality risk and 0.539 (95% CI: 0.462-0.607) with morbidity risk. Internal consistency yielded a standardized Cronbach's alpha of 0.8; inter-rater reliability resulted in a reliability coefficient of 0.98 for the quantitative index and a weighted global Kappa coefficient of 0.87 for the ordinal surgical index of severity for surgical services (IGQ). CONCLUSIONS: The validity and reliability of the proposed index was satisfactory in all aspects evaluated. The surgical services severity index may be used in the original context and is easily adaptable to other contexts as well.

En el contexto de la evaluación de servicios hospitalarios, la incorporación de índices de gravedad permite tener una variable de control esencial para la comparación del desempeño en el tiempo y el espacio a través del llamado ajuste por riesgo. El índice de gravedad para servicios quirúrgicos, se construyó en 1999 y se validó como un índice general para estos servicios. Dieciséis años después el contexto hospitalario ha cambiado y se consideró necesaria una revalidación de este índice de gravedad que avale su utilidad actual.

Índice de gravedad para servicios quirúrgicos en un hospital cubano: estudio de revalidación / Severity of illness index for surgical departments in a Cuban hospital: a revalidation study

INTRODUCCIÓN En el contexto de la evaluación de servicios hospitalarios, la incorporación de índices de gravedad permite tener una variable de control esencial para la comparación del desempeño en el tiempo y el espacio a través del llamado ajuste por riesgo. El índice de gravedad para servicios quirúrgicos, se construyó en 1999 y se validó como un índice general para estos servicios. Dieciséis años después el contexto hospitalario ha cambiado y se consideró necesaria una revalidación de este índice de gravedad que avale su utilidad actual. OBJETIVO Evaluar la validez y confiabilidad del índice de gravedad para servicios quirúrgicos, que avale su uso razonable en las condiciones actuales. MÉTODOS Se realizó una investigación descriptiva retrospectiva en el servicio de cirugía general del Hospital Clínico Quirúrgico Hermanos Ameijeiras en el segundo semestre del año 2010. Se revisaron las historias clínicas de 511 pacientes egresados de este servicio. Las variables utilizadas fueron las mismas del índice original con sus ponderaciones. Se evaluaron validez conceptual o de constructo, validez de criterio y confiabilidad interevaluadores así como consistencia interna del índice propuesto. RESULTADOS La validez de constructo se expresó en una asociación significativa entre el valor del índice de gravedad para servicios quirúrgicos y el estado al egreso. Se comprobó también correlación significativa, aunque débil, con la estadía hospitalaria. En cuanto a validez de criterio, la correlación entre el índice de gravedad propuesto y el índice de Horn fue de 0,722 (intervalo de confianza de 95%: 0,677-0,761); mientras que con el índice Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) la correlación fue de 0,454 (intervalo de confianza de 95%: 0,388-0,514) con el riesgo de muerte y 0,539 (intervalo de confianza de 95%: 0,462-0,607) con el riesgo de morbilidad. La consistencia interna mostró α de Cronbach estandarizado de 0,8; la confiabilidad interevaluadores resultó en un coeficiente de confiabilidad de 0,98 para el índice de gravedad para servicios quirúrgicos cuantitativo y un coeficiente de κ ponderado global de 0,87 para el índice de gravedad para servicios quirúrgicos ordinal. CONCLUSIONES La validez y confiabilidad del índice propuesto fue adecuada en todos los aspectos evaluados. El índice de gravedad para servicios quirúrgicos puede utilizarse en el contexto original y es fácilmente adaptable a otros contextos.

INTRODUCTION In the context of the evaluation of hospital services, the incorporation of severity indices allows an essential control variable for performance comparisons in time and space through risk adjustment. The severity index for surgical services was developed in 1999 and validated as a general index for surgical services. Sixteen years later the hospital context is different in many ways and a revalidation was considered necessary to guarantee its current usefulness. OBJECTIVE To evaluate the validity and reliability of the surgical services severity index to warrant its reasonable use under current conditions. METHODS A descriptive study was carried out in the General Surgery service of the "Hermanos Ameijeiras" Clinical Surgical Hospital of Havana, Cuba during the second half of 2010. We reviewed the medical records of 511 patients discharged from this service. Items were the same as the original index as were their weighted values. Conceptual or construct validity, criterion validity and inter-rater reliability as well as internal consistency of the proposed index were evaluated. RESULTS Construct validity was expressed as a significant association between the value of the severity index for surgical services and discharge status. A significant association was also found, although weak, with length of hospital stay. Criterion validity was demonstrated through the correlations between the severity index for surgical services and other similar indices. Regarding criterion validity, the Horn index showed a correlation of 0.722 (95% CI: 0.677-0.761) with our index. With the POSSUM score, correlation was 0.454 (95% CI: 0.388-0.514) with mortality risk and 0.539 (95% CI: 0.462-0.607) with morbidity risk. Internal consistency yielded a standardized Cronbach's alpha of 0.8; inter-rater reliability resulted in a reliability coefficient of 0.98 for the quantitative index and a weighted global Kappa coefficient of 0.87 for the ordinal surgical index of severity for surgical services (IGQ). CONCLUSIONS The validity and reliability of the proposed index was satisfactory in all aspects evaluated. The surgical services severity index may be used in the original context and is easily adaptable to other contexts as well.

Índice de internación ajustado por riesgo en hospitales públicos de Costa Rica / Risk-Adjusted Hospitalization Rate in Public Hospitals in Costa Rica / Índice de internamente ajustado por risco em hospitais públicos na Costa Rica

Resumen La estancia prolongada constituye un importante problema de gestión hospitalaria. El objetivo de este estudio es estimar un índice que identifique los hospitales con una gestión inadecuada de las estancias. El índice de adecuación de estancias se calcula dividiendo las estancias observadas entre las estancias esperadas en cada hospital. Estas últimas se estiman con un modelo de regresión que considera las características sociodemográficas y clínicas de los pacientes. Se utiliza la base de egresos hospitalarios del seguro público de salud de Costa Rica del 2014. El 43% de los hospitales tiene una inadecuada gestión de las estancias, dado que registran mayores días de hospitalización que los esperados, de acuerdo a lo que le correspondía por la casuística. Se concluye que la información clínico-administrativa del sistema público de Costa Rica permite estimar un índice de adecuación de estancias, para identificar los hospitales con una gestión inadecuada de las estancias.

Abstract A prolonged hospitalization constitutes an important hospital management problem. The purpose of this study is to calculate an index which identifies the hospitals with an inadequate hospitalization management. The hospitalization adequacy index is calculated by dividing the observed hospitalizations by the expected hospitalizations in each hospital. The latter are calculated with a regression model which takes into account the socio-demographic and clinical characteristics of the patients. We use the basis of hospitalization discharges of the public healthcare system in Costa Rica for 2014. 43% of the hospitals have an inadequate hospitalization management, as they record more hospitalization days than expected according to the corresponding case load. We conclude that the clinical-management information of the Costa Rican public healthcare allows us to estimate a hospitalization adequacy index as to identify hospitals with an inadequate hospitalization management.

Resumo A estancia prolongada constitui importante problema de gestão hospitalar. O objetivo deste estudo foi estimar um índice que identifique os hospitais com gestão inadequada das estancias. O índice de adequação de estancias é calculado dividindo as estancias observadas entre as estancias esperadas em cada hospital. Estas últimas foram estimadas com um modelo de regressão que considera as características sociodemográficas e clínicas dos pacientes. Utiliza-se a base de egressos hospitalares do seguro público de saúde de Costa Rica de 2014. O 43% dos hospitais tem inadequada gestão das estancias, dado que registram mais dias de hospitalização do que os esperados, de acordo com o esperado por casuística. Concluise que a informação clínico-administrativa do sistema público de Costa Rica permite estimar um índice de adequação de estancias, para identificar os hospitais com gestão inadequada das estancias.

Analysis of surgical mortality for congenital heart defects using rachs-1 risk score in a brazilian single center

ABSTRACT Introduction: Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) score is a simple model that can be easily applied and has been widely used for mortality comparison among pediatric cardiovascular services. It is based on the categorization of several surgical palliative or corrective procedures, which have similar mortality in the treatment of congenital heart disease. Objective: To analyze the in-hospital mortality in pediatric patients (<18 years) submitted to cardiac surgery for congenital heart disease based on RACHS-1 score, during a 12-year period. Methods: A retrospective date analysis was performed from January 2003 to December 2014. The survey was divided in two periods of six years long each, to check for any improvement in the results. We evaluated the numbers of procedures performed, complexity of surgery and hospital mortality. Results: Three thousand and two hundred and one surgeries were performed. Of these, 3071 were able to be classified according to the score RACHS-1. Among the patients, 51.7% were male and 47.5% were younger than one year of age. The most common RACHS-1 category was 3 (35.5%). The mortality was 1.8%, 5.5%, 14.9%, 32.5% and 68.6% for category 1, 2, 3, 4 and 6, respectively. There was a significant increase in the number of surgeries (48%) and a significant reduction in the mortality in the last period analysed (13.3% in period I and 10.4% in period II; P=0.014). Conclusion: RACHS-1 score was a useful score for mortality risk in our service, although we are aware that other factors have an impact on the total mortality.

Gasto farmacéutico en diabetes mellitus en una región de España según el Clinical Risk Group, 2012 / Pharmaceutical Expenditure for Diabetes Mellitus in a Region of Spain as Clinical Risk Group, 2012 / Despesa com medicamentos em pacientes com diabetes mellitus em uma região da Espanha como o Grupo de Risco Clínico de 2012

Se pretende estimar la multimorbilidad asociada con diabetes mellitus tipo 2 y su relación con el gasto farmacéutico, para lo cual se realizó un estudio de corte transversal durante el año 2012. Se identificó a 350 015 individuos diabéticos, a través de códigos clínicos, usando la Clasificación Internacional de Enfermedades y el software 3M Clinical Risk Groups. Todos los pacientes fueron clasificados en cuatro grupos de morbilidad. El primer grupo corresponde al estadio inicial, el segundo grupo incluye el núcleo de multimorbilidad de pacientes en fases intermedia y avanzada, el tercer grupo incluye pacientes con diabetes y enfermedades malignas, y el último grupo es de pacientes en estado catastrófico, principalmente enfermos renales crónicos. La prevalencia bruta de diabetes fue de 6,7%. El gasto promedio total fue de ¬ 1257,1. La diabetes se caracteriza por una fuerte presencia de otras condiciones crónicas y tiene un gran impacto en el gasto farmacéutico.

Estimations of multimorbidity associated with Type 2 Diabetes Mellitus and its relationship to pharmaceutical expenditure. Cross-sectional study during 2012. 350,015 diabetic individuals, identified through clinical codes using the International Statistical Classification of Diseases and Related Health Problem and the 3M Clinical Risk Groups software. The raw prevalence of diabetes was 6.7%. All patients were stratified into four morbidity groups. The first group corresponds to the initial state; the second group includes the core multimorbidity patients in the intermediate and advanced stages; the third group includes patients with diabetes and malignancies; the last group patients with catastrophic statuses, manly chronic renal patients. The raw prevalence of diabetes was 6.7%. The average total cost was ¬ 1257.1. Diabetes is characterized by a strong presence of other chronic conditions have a great impact on pharmaceutical spending.

As estimativas de vários morbidade associada com diabetes mellitus tipo 2 e sua relação com a despesa farmacêutica, para o qual um estudo transversal foi realizado em 2012. Ele foi identificado em 350 015 indivíduos diabéticos, foram identificados através códigos clínicos, utilizando a Classificação Internacional de Doenças e Risco clínica software Grupos 3M. Todos os pacientes foram classificados em quatro grupos de doença 4. O primeiro grupo corresponde à fase inicial (CRG 1-4); O segundo grupo inclui pacientes multimorbid principais fases intermediárias e avançadas, o terceiro grupo inclui pacientes com diabetes e doenças malignas, eo último grupo de pacientes em estado catastrófico, pacientes renais crónicos, principalmente. A prevalência global de diabetes foi de 6,7%. A despesa média total foi de ¬ 1257,1. Diabetes que se caracteriza por uma forte presença de outras condições crónicas e tieniendo um grande impacto sobre os gastos farmacêutica.