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Dale W Bratzler

Publications and source records attributed to Dale W Bratzler.

At least 19 recordsLinked to original sources
PubMed2006

Assessment of the Medicare quality improvement organization program.

BACKGROUND: Studies have shown improvement in quality of health care in the United States. However, the factors responsible for this improvement are largely unknown. OBJECTIVE: To evaluate the effect of the Medicare Quality Improvement Organization (QIO) Program in 4 clinical settings by using performance data for 41 quality measures during the 7th Scope of Work. DESIGN: Observational study in which differences in quality measures were compared between baseline and remeasurement periods for providers that received different levels of QIO interventions. SETTING: Nursing homes, home health agencies, hospitals, and physician offices in the 50 U.S. states, the District of Columbia, and 2 U.S. territories. PARTICIPANTS: Providers receiving focused QIO assistance related to quality measures and providers receiving general informational assistance from QIOs. MEASUREMENTS: 5 nursing home quality measures, 11 home health measures, 21 hospital measures, and 4 physician office measures. RESULTS: For nursing home, home health, and physician office measures, providers recruited specifically by QIOs for receipt of assistance showed greater improvement in performance on 18 of 20 measures than did providers who were not recruited; similar improvement was seen on the other 2 measures. Nursing homes and home health agencies improved more in all measures on which they chose to work with the QIO than in other measures. Nineteen of 21 hospital measures showed improvement; in this setting, QIOs were contracted for improvement initiatives solely at the statewide level. Overall, improvement was seen in 34 of 41 measures from baseline to remeasurement in the 7th Scope of Work. LIMITATIONS: As in any observational study, selection bias, regression to the mean, and secular trends may have influenced the results. CONCLUSIONS: These findings are consistent with an impact of the QIO Program and QIO technical assistance on the observed improvement. Future evaluations of the QIO Program will attempt to better address the limitations of the design of this study.

Emergency Medical Services↗
PubMed2006

The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.

Among the most common complications that occur after surgery are surgical site infections and postoperative sepsis, cardiovascular complications, respiratory complications (including postoperative pneumonia), and thromboembolic complications. Patients who experience postoperative complications have dramatically increased hospital length of stay, hospital costs, and mortality rates. The Centers for Medicare & Medicaid Services, in collaboration with the Centers for Disease Control and Prevention, has implemented the Surgical Infection Prevention Project to decrease the morbidity and mortality associated with postoperative surgical site infections. More recently, the Surgical Care Improvement Project, a national quality partnership of organizations committed to improving the safety of surgical care, has been announced. This review will provide an update from the Surgical Infection Prevention Project and provide an introduction to the Surgical Care Improvement Project.

Antibiotic Prophylaxis↗
PubMed2006

Volume, quality of care, and outcome in pneumonia.

BACKGROUND: The establishment of minimum volume thresholds has been proposed as a means of improving outcomes for patients with various medical and surgical conditions. OBJECTIVE: To determine whether volume is associated with either quality of care or outcome in the treatment of pneumonia. DESIGN: Retrospective cohort study. SETTING: 3243 hospitals participating in the National Pneumonia Quality Improvement Project in 1998 and 1999. PATIENTS: 13,480 patients with pneumonia cared for by 9741 physicians. MEASUREMENTS: The association between the annual pneumonia caseload of physicians and hospitals and adherence to quality-of-care measures and severity-adjusted in-hospital and 30-day mortality rates. RESULTS: Physician volume was unrelated to the timeliness of administration of antibiotics and the obtainment of blood cultures; however, physicians in the highest-volume quartile had lower rates of screening for and administration of influenza (21%, 19%, 20%, and 12% for quartiles 1 through 4, respectively; P < 0.01) and pneumococcal (16%, 13%, 13%, and 9% for quartiles 1 through 4, respectively; P < 0.01) vaccines. Among hospitals, the percentage of patients who received antibiotics within 4 hours of hospital arrival was inversely related to pneumonia volume (72%, 64%, 60%, and 56% for quartiles 1 through 4, respectively; P < 0.01), while selection of antibiotic, obtainment of blood cultures, and rates of immunization were similar. Physician volume was not associated with in-hospital or 30-day mortality rates. Odds ratios for in-hospital mortality rates rose with increasing hospital volume (1.14 [95% CI, 0.87 to 1.49], 1.34 [CI, 1.03 to 1.75], and 1.32 [CI, 0.97 to 1.80] for quartiles 2 to 4, respectively); however, odds ratios for 30-day mortality rates were similar. LIMITATIONS: This study was limited to Medicare beneficiaries 65 years of age and older. Ascertainment of some measures of the quality of care and severity of illness depended on the documentation practices of the physician. CONCLUSION: Among both physicians and hospitals, higher pneumonia volume is associated with reduced adherence to selected guideline recommendations and no measurable improvement in patient outcomes.

Aged↗
PubMed2006

In-hospital observation after antibiotic switch in pneumonia: a national evaluation.

PURPOSE: To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary. METHODS: We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a "not observed" cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an "observed for 1 day" cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts. RESULTS: A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 "not observed" and 2712 "observed for 1 day" patients). Mean length of stay was 3.8 days for the "not observed" cohort and 4.5 days for the "observed for 1 day" cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the "not observed" cohort vs 7.2% "observed for 1 day" cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% "not observed" cohort vs 4.4% in the "observed for 1 day" cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the "not observed" and "observed for 1 day" cohorts. CONCLUSIONS: Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.

Administration, Oral↗
PubMed2006

Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?

BACKGROUND: Many organizations, including the Centers for Medicare & Medicaid Services, measure the percentage of patients hospitalized with pneumonia who receive antibiotics within 4 h of presentation. Because the diagnosis of pneumonia can be delayed in patients with an atypical presentation, there are concerns that attempts to achieve a performance target of 100% may encourage inappropriate antibiotic usage and the diversion of limited resources from seriously ill patients. This study was performed to determine how frequently Medicare patients with a hospital discharge diagnosis of pneumonia present in a manner that could potentially lead to diagnostic uncertainty and a resulting appropriate delay in antibiotic administration. METHODS: Randomly selected charts of hospitalized Medicare patients who have received diagnoses of pneumonia were reviewed independently by three reviewers to determine whether there was a potential reason for a delay of antibiotic administration other than quality of care. Antibiotic administration timing, patient demographic, and clinical characteristics were also abstracted. RESULTS: Nineteen of 86 patients (22%; 95% confidence interval, 13.7 to 32.2) presented in a manner that had the potential to result in delayed antibiotic treatment due to diagnostic uncertainty. Diagnostic uncertainty was significantly associated with the lack of rales, normal pulse oximetry findings, and lack of an infiltrate seen on the chest radiograph. There was a nonsignificant trend toward a longer time until antibiotic treatment in patients with diagnostic uncertainty. CONCLUSIONS: Many Medicare patients in whom pneumonia has been diagnosed present in an atypical manner. Delivering antibiotic treatment within 4 h for all patients would necessitate the treatment of many patients before a firm diagnosis can be made.

Aged↗
PubMed2005

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project.

HYPOTHESIS: Surgical site infections (SSIs) are a major contributor to patient injury, mortality, and health care costs. Despite evidence of effectiveness of antimicrobials to prevent SSIs, previous studies have demonstrated inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis. We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery. DESIGN: National retrospective cohort study with medical record review. SETTING: Two thousand nine hundred sixty-five acute-care US hospitals. PATIENTS: A systematic random sample of 34,133 Medicare inpatients undergoing coronary artery bypass grafting; other open-chest cardiac surgery (excluding transplantation); vascular surgery, including aneurysm repair, thromboendarterectomy, and vein bypass operations; general abdominal colorectal surgery; hip and knee total joint arthroplasty (excluding revision surgery); and abdominal and vaginal hysterectomy from January 1 through November 30, 2001. MAIN OUTCOME MEASURES: The proportion of patients who had parenteral antimicrobial prophylaxis initiated within 1 hour before the surgical incision; the proportion of patients who were given a prophylactic antimicrobial agent that was consistent with currently published guidelines; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery. RESULTS: An antimicrobial dose was administered to 55.7% (95% confidence interval [CI], 54.8%-56.6%) of patients within 1 hour before incision. Antimicrobial agents consistent with published guidelines were administered to 92.6% (95% CI, 92.3%-92.8%) of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% (95% CI, 40.2%-41.2%) of patients. CONCLUSION: Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.

Aged↗
PubMed2005

Hospitals collaborate to decrease surgical site infections.

BACKGROUND: Despite a large body of evidence describing care processes known to reduce the incidence of surgical site infections, many are underutilized in practice. METHODS: Fifty-six hospitals volunteered to redesign their systems as part of the National Surgical Infection Prevention Collaborative, a 1-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Each facility selected quality improvement objectives for a select group of surgical procedures and reported monthly clinical process measure data. RESULTS: Forty-four hospitals reported data on 35,543 surgical cases. Hospitals improved in measures related to appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. The infection rate decreased 27%, from 2.3% to 1.7% in the first versus last 3 months. CONCLUSIONS: The Collaborative demonstrated improvement in processes known to be associated with reduced risk of surgical site infections. Quality improvement organizations can be effective resources for quality improvement in the surgical arena.

Cooperative Behavior↗
PubMed2005

Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project.

In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting. The objectives were to review areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges. The workgroup reviewed currently published guidelines for antimicrobial prophylaxis. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection.

Antibiotic Prophylaxis↗
PubMed2005

Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes?

PURPOSE OF REVIEW: Associations between processes of care for hospitalized community-acquired pneumonia patients and clinical outcomes are important because of the high incidence of such admissions and substantial related mortality. Several studies have examined these associations. RECENT FINDINGS: Large retrospective studies of older patients have demonstrated associations between time to first dose as short as 4 h and length of stay and mortality during and after hospitalization. Results of smaller studies have been less consistent. The association appears to be strongest among older patients who have not received antibiotics prior to arrival at the hospital. SUMMARY: A significant and causal relationship appears to exist between antibiotic timing and improved outcomes, especially among older patients. Even modest improvements in timeliness of antibiotic administration could impact a substantial number of lives because of the high incidence of community-acquired pneumonia hospitalization.

Anti-Bacterial Agents↗
PubMed2005

Blood culture and susceptibility results and allergy history do not influence fluoroquinolone use in the treatment of community-acquired pneumonia.

STUDY OBJECTIVE: To determine the influence of blood culture and susceptibility results and antimicrobial allergy history on fluoroquinolone use in the treatment of community-acquired pneumonia. DESIGN: Retrospective analysis of medical records. SETTING: Centers for Medicare and Medicaid Services, Seattle, Washington. PATIENTS: A total of 10,275 Medicare beneficiaries hospitalized with the diagnosis of pneumonia received antimicrobial treatment within 24 hours of admission. Of these patients, 288 had blood cultures positive for pneumococcus and were matched one-to-one with patients with negative blood and sputum cultures. MEASUREMENTS AND MAIN RESULTS: Antimicrobial use at the beginning and end of hospitalization, culture and susceptibility results, and patient allergies were recorded retrospectively and compared between two matched groups: patients with blood cultures positive for Streptococcus pneumoniae and those whose blood and sputum cultures were negative. Neither culture and susceptibility results nor allergy history affected the rate of fluoroquinolone use. Despite infection due to penicillin-susceptible pneumococci and no penicillin allergy, patients received therapy with fluoroquinolones (26.7%) as frequently as those with culture-negative pneumonia (34.9%; p=0.401). CONCLUSION: Fluoroquinolones are prescribed despite microbiologic confirmation of penicillin-susceptible pneumococcal pneumonia in the absence of penicillin allergy. These prescribing patterns may contribute to selection pressure associated with fluoroquinolone-resistant gram-positive and gram-negative bacteria.

Blood↗
PubMed2004

Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project.

In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting. The objectives were to review areas of agreement among the most-recently published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the groups that have published North American guidelines for antimicrobial prophylaxis, as well as authors from several specialty colleges. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of SIPGWW include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.

Anti-Bacterial Agents↗
PubMed2004

Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.

BACKGROUND: Pneumonia accounts for more than 600 000 Medicare hospitalizations yearly. Guidelines have recommended antibiotic treatment within 8 hours of arrival at the hospital. METHODS: We performed a retrospective study using medical records from a national random sample of 18 209 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia from July 1998 through March 1999. Outcomes were severity-adjusted mortality, readmission within 30 days of discharge, and length of stay (LOS). RESULTS: Among 13 771 (75.6%) patients who had not received outpatient antibiotic agents, antibiotic administration within 4 hours of arrival at the hospital was associated with reduced in-hospital mortality (6.8% vs 7.4%; adjusted odds ratio [AOR], 0.85; 95% confidence interval [CI], 0.74-0.98), mortality within 30 days of admission (11.6% vs 12.7%; AOR, 0.85; 95% CI, 0.76-0.95), and LOS exceeding the 5-day median (42.1% vs 45.1%; AOR, 0.90; 95% CI, 0.83-0.96). Mean LOS was 0.4 days shorter with antibiotic administration within 4 hours than with later administration. Timing was not associated with readmission. Antibiotic administration within 4 hours of arrival was documented for 60.9% of all patients and for more than 50% of patients regardless of hospital characteristics. CONCLUSIONS: Antibiotic administration within 4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients. Administration within 4 hours can prevent deaths in the Medicare population, offers cost savings for hospitals, and is feasible for most inpatients.

Aged↗
PubMed2004

Is signed consent for influenza or pneumococcal polysaccharide vaccination required?

Each year, thousands of preventable deaths and hospitalizations result from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Obtaining signed consent prior to administering the vaccines represents an obstacle to achieving the Healthy People 2010 goals for vaccinating individuals against influenza and pneumococcal disease. Signed consent is neither legally mandated nor a guarantee that the patient (or proxy) has given informed consent. Nonetheless, many health care providers and institutions currently require signed consent before administering these vaccines. Rather, health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with these vaccines. Requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments, eg, antibiotic treatment, whose risk levels are the same or higher.

Centers for Disease Control and Prevention, U.S.↗
PubMed2004

Multistate improvement in process and outcomes of carotid endarterectomy.

OBJECTIVES: The purpose of this study was to assess the effect of community-wide performance measurement and feedback on key processes and outcomes of carotid endarterectomy (CEA). METHODS: Complete medical record (hospital chart) review for indications, care processes, and outcomes was performed on a random sample of Medicare patients undergoing CEA in 10 states (Arkansas, Georgia, Illinois, Indiana, Iowa, Kentucky, Michigan, Nebraska, Ohio, Oklahoma) during baseline (Jun 1, 1995 to May 31, 1996) and remeasurement (Jun 1, 1998 to May 31, 1999) periods. In addition to review of the index hospital stay, hospital admissions within 30 days of the procedure were reviewed and the Medicare enrollment database queried to identify out-of-hospital deaths, to determine 30-day outcome results. The baseline data by state were provided to the Medicare Quality Improvement Organizations (QIOs) in the respective states, and quality improvement initiatives were encouraged. RESULTS: We reviewed 9945 primary CEA alone procedures, 236 CEA and coronary artery bypass grafting (CABG) procedures, and 380 repeat CEA operations during the baseline period (B), and 9745 primary CEA alone procedures, 233 CEA and CABG procedures, and 401 repeat CEA operations during the remeasurement period (R). There was a significant decrease in the combined event rate (30-day stroke or mortality) for CEA alone procedures between baseline and remeasurement (B, 5.6%; R, 5.0%). A decrease occurred in each of the indication strata; transient ischemic attack or stroke (B, 7.7%; R, 6.9%), nonspecific symptoms (B, 5.9%; R, 5.4%), and no symptoms (B, 4.1%; R, 3.8%). The combined event rate also decreased for CEA and CABG (B, 17.4%; R, 13.3%) and repeat CEA operations (B, 6.8%; R, 5.7%). The remeasurement period state-to-state variation in combined event rate for CEA alone ranged from 2.7% (Georgia) to 5.9% (Indiana) for all indications combined, from 4.4% (Georgia) to 10.9% (Michigan) in patients with recent transient ischemia or stroke, from 1.4% (Georgia) to 6.0% (Oklahoma) in patients with no symptoms, and from 3.7% (Georgia) to 7.9% (Indiana) in patients with nonspecific symptoms. There were significant increases in preoperative antiplatelet administration (62%-67%; P <.0001) and patching (29%-45%; P =.05) from baseline to remeasurement in the CEA alone subset. Preoperative antiplatelet administration and patching were associated with improved outcomes in the combined baseline and remeasurement data. CONCLUSIONS: Community-wide quality improvement initiatives with performance measurement and confidential reporting of provider level data can lead to improvement in important care processes and outcomes. There is considerable variation between states in outcome and process, and thus continued room for improvement. Quality improvement projects that include standardized confidential outcome reporting should be encouraged. Preoperative antiplatelet therapy administration and patching rates should be considered as evidence-based performance measures.

Coronary Artery Bypass↗
PubMed2004

Management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: physician practices in the community hospital setting.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and sixth most common reason that Medicare patients are hospitalized. We performed retrospective chart review on a statewide random sample of 409 Medicare patients discharged from October 1, 2000, through January 31, 2001, with a diagnosis of COPD. The most commonly performed diagnostic tests were chest radiography (96.8%) and oxygenation assessment (94.9%). The most common treatments provided were inhaled short-acting beta-agonist bronchodilators (98.5%) and oxygen (94.4%). Antibiotics (89.0%) and systemic corticosteroids (85.1%) were prescribed less frequently. The median length of stay was 5 days. The readmission rate was 27.4% (CI, 23.1-32.0) at 30 days and 43.0% (CI, 38.2-47.9) at 180 days. The in-hospital mortality rate was 1.7% (CI, 0.7-3.5) and the 180-day mortality rate was 23.7% (CI, 19.7-28.1). The morbidity and mortality associated with acute exacerbations of COPD remain high. There are opportunities to improve quality of care for this condition.

Acute Disease↗