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PubMed2006

Are registry hospitals different? A comparison of patients admitted to hospitals of a commercial heart failure registry with those from national and community cohorts.

BACKGROUND: Clinical registries have been created to address questions that are difficult to answer with clinical trials. However, the applicability of registry findings to the general population has been questioned because of concerns over potential bias in the selection of participating hospitals. The purpose of this study was to determine if patients admitted to hospitals participating in a heart failure registry (ADHERE) are comparable with patients admitted to other hospitals, including those admitted to Framingham area hospitals. METHODS: We used a 20% random sample of all Medicare patients discharged during 1984 to 2001 to determine rates of hospitalization, procedure use, and survival after a first admission for heart failure (none in the prior 3 years). Hospitals were classified as participating in the ADHERE registry (n = 189), located within or near Framingham, MA (n = 9), or other (n = 5541). RESULTS: A total of 725,702 first admissions were identified, including 80,338 to ADHERE hospitals and 1716 to Framingham area hospitals. Minimal differences in patient characteristics were noted between patients admitted to ADHERE and non-ADHERE hospitals, although patients admitted to Framingham area hospitals were more likely to be white (95%) than were patients admitted to ADHERE (84%) or other hospitals (87%, P < .0001). Mortality at 1 year was 35.8% for ADHERE, 36.2% for other hospitalized patients, and 32.9% for Framingham patients (P < .0001). Rehospitalization for heart failure at 90 days was 13.0% for following admission to ADHERE, 13.0% to other hospitals, and 16.4% to Framingham hospitals (P = .0004). After adjustment for patient characteristics, differences in outcome between ADHERE and non-ADHERE hospitals remained minimal. CONCLUSION: Patients admitted with heart failure to ADHERE registry hospitals had similar baseline characteristics and outcomes to other patients.

Aged↗
PubMed1998

Public disclosure of performance information in Pennsylvania: impact on hospital charges and the views of hospital executives.

BACKGROUND: Forty states have now passed legislation establishing governmental agencies charged with the task of gathering hospital-level data. Since 1988 all acute care hospitals in Pennsylvania have been submitting data to the Pennsylvania Health Care Cost Containment Council (PHC4). Pennsylvania's policy was designed to make patients and purchasers more informed and selective buyers of medical services, to increase the public accountability of providers of these services, and to encourage hospitals and physicians to compete more on clinical outcomes and charges. The impact of Pennsylvania's policy of public disclosure of performance information on hospital charges over time has not previously been evaluated. Nor has the importance that hospital executives assign to the publication of comparative charges and clinical outcomes information been assessed. METHODS: From 1990 through 1994 the PHC4 published a number of hospital-level performance reports (including the regional Hospital Effectiveness Reports and A Consumer's Guide to Coronary Artery Bypass Graft Surgery) containing hospital average charges, average lengths of stay, a rating of severity of illness, and two outcome measurements--morbidity and in-hospital mortality--on a total of 59 diagnosis-related groups. An 18-item survey designed to assess hospital executives' opinions of the usefulness and importance of the PCH4 information was sent to the chief executive officers at the study hospitals. DISCUSSION: There were no significant trends toward a reduction in the dispersion of charges in either category of hospitals during the study period. Most hospital executives assigned low ratings of importance to published comparative charges information; however, executives of high-competition hospitals assigned significantly higher importance ratings to the information as a whole in enouraging hospital competition based on quality.

Attitude of Health Personnel↗
PubMed1998

Do general practitioner hospitals reduce the utilisation of general hospital beds? Evidence from Finnmark county in north Norway.

STUDY OBJECTIVE: To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. DESIGN: Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. SETTING: Two general hospitals serving the population of Finnmark county in north Norway. PATIENTS: 35,435 admissions based on five years' routine recordings from the two hospitals. MAIN RESULTS: The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. CONCLUSION: GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.

Adolescent↗
PubMed2007

Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations.

CONTEXT: Postpartum psychosis occurs in 1 to 2 cases per 1000 live births. Most studies have not distinguished postpartum psychosis from bipolar disorder or the proportion of the incidence attributable to prepregnancy psychiatric morbidity. OBJECTIVE: To determine the incidence of postpartum psychosis and bipolar disorder attributable to previous psychiatric hospitalization. DESIGN: Population-based study using linked registry data to determine postpartum onset of psychotic and bipolar episodes within 90 days after the first birth, by women with and without prepregnancy or prenatal psychiatric hospitalization. We assessed the type, number, and recency of previous hospitalizations on the incidence of hospitalization for postpartum psychotic and bipolar episodes. SETTING: Nationwide Swedish Hospital Discharge and Medical Birth registers. PATIENTS: Swedish women delivering a first live infant between January 1, 1987, and December 31, 2001. MAIN OUTCOME MEASURES: Postpartum hospitalization for psychosis or bipolar disorder. RESULTS: The cumulative incidences for postpartum psychotic and bipolar episodes (adjusted for age at first birth) were 0.07% and 0.03%, respectively. The incidence of psychiatric hospitalizations for postpartum psychotic or bipolar episodes among women without previous psychiatric hospitalizations was 0.04% and 0.01% of first births, respectively; for women with any psychiatric hospitalization before delivery, the incidence was 9.24% and 4.48%, respectively. For postpartum psychotic and bipolar episodes, the risk increased significantly with the recency of prepregnancy hospitalizations, number of previous hospitalizations, and length of most recent hospitalization. More than 40% of women hospitalized during the prenatal period for a bipolar or a psychotic condition were hospitalized again during the postpartum period. Approximately 90% of all postpartum psychotic and bipolar episodes occurred within the first 4 weeks after delivery. CONCLUSIONS: Almost 10% of women hospitalized for psychiatric morbidity before delivery develop postpartum psychosis after their first birth. This underscores the need for obstetricians to assess history of psychiatric symptoms and, with pediatric and psychiatric colleagues, to optimize the treatment of mothers with psychiatric diagnoses through childbirth.

Adult↗
PubMed2003

Impact of pre-hospital care in patients with acute myocardial infarction compared with those first managed in-hospital.

AIMS: To compare prospectively the impact of pre-hospital care by a physician-staffed mobile coronary care unit with patients managed initially in-hospital, all with acute myocardial infarction. METHODS AND RESULTS: This was a single centre registry of consecutive patients (n=750) admitted with acute myocardial infarction to the coronary care unit and cardiology wards of the Royal Victoria Hospital, Belfast between 1998 and 2001. For the 750 patients, in-hospital mortality was 11% and was significantly lower for those managed pre-hospital (8% vs 13%, P=0.04): patients who received fibrinolytic therapy (n=474), the in-hospital mortality was significantly lower in the pre-hospital group (7% vs 13%, P=0.02). Those managed pre-hospital had significant reduction in the median delay times (25th, 75th percentiles) from onset of symptoms to call for help 1.0 (0.5, 2.2) vs 2.0 (0.9, 6.0) h, P<0.001, from call for help to receiving fibrinolytic therapy 1.0 (0.8, 1.5) vs 1.8 (1.2, 2.5) h, P<0.001 resulting in a shorter pain-to-needle time for fibrinolytic therapy 2.3 (1.5, 3.8) vs 4.0 (2.6, 7.2) h, P<0.001. For all patients, older age, haemodynamic indicators on admission (hypotension, higher heart rate, heart failure) and managed by the in-hospital route were significant independent variables for an adverse in-hospital mortality. Although for patients aged >or=75 years no statistical significant reduction in mortality occurred for those managed pre-hospital (P=0.051), nevertheless patients in this age group first treated pre-hospital who received fibrinolytic therapy had a significantly lower mortality than those first treated in-hospital (21% vs 43%, P=0.02). CONCLUSIONS: Consecutive patients with acute myocardial infarction seen and managed initially out-of-hospital by a physician-staffed mobile coronary care unit had significantly lower in-hospital mortality.

Adult↗
PubMed2003

The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals.

BACKGROUND: It is unclear whether publicly reporting hospitals' risk-adjusted mortality affects market share and mortality at outlier hospitals. OBJECTIVES: To examine hospitals' market share and risk-adjusted mortality from 1991 to 1997 at hospitals participating in Cleveland Health Quality Choice (CHQC). RESEARCH DESIGN: Time series. SUBJECTS: Changes in market share were examined for all patients hospitalized with acute myocardial infarction, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, or stroke at all 30 nonfederal hospitals in Northeast Ohio. Patients insured by Medicare were used to examine changes in mortality. MEASURES: Trends in market share (proportion of patients with the target conditions discharged from a given hospital) and risk-adjusted 30-day mortality. RESULTS: CHQC identified several hospitals with consistently higher than expected mortality. The five hospitals with the highest mortality tended to lose market share (mean change -0.6%, 95% CI -1.9-0.6), but this was not significant. The only outlier hospital with a large decline in market share had declining volume for 2 years before being declared an outlier. Risk-adjusted mortality declined only slightly at hospitals classified by us as "below average" (-0.8%; 95% CI, 2.9-1.8%) or "worst" (-0.4%; 95% CI -2.3-1.7). However, risk-adjusted mortality at one hospital changed from consistently above expected to consistently below expected shortly after first being declared an outlier. CONCLUSION: Despite CHQC's strengths, identifying hospitals with higher than expected mortality did not adversely affect their market share or, with one exception, lead to improved outcomes. This failure may have resulted from consumer disinterest or difficulty interpreting CHQC reports, unwillingness of businesses to create incentives targeted to hospitals' performance, and hospitals' inability to develop effective quality improvement programs.

Consumer Behavior↗
PubMed2006

Free tissue transfer: comparison of outcomes between university hospitals and community hospitals.

BACKGROUND: In university hospitals, free tissue transfer has become a standard method of reconstruction for a broad spectrum of defects. Because of its complexity, free tissue transfer has not been routinely performed in a community hospital setting. This study reports the outcomes of two equal groups of free tissue transfer performed by the same surgeons, comparing the university versus the community hospital setting. METHODS: A total of 735 free tissue transfers were performed at one university hospital and six community hospitals in our region over a 10-year study period. Outcome parameters used in this study included wound complications such as infection, dehiscence, delayed healing, hematoma, and fat necrosis. RESULTS: A total of 674 operations were performed using 735 free tissue transfers: 386 free tissue transfers were performed at the university hospital (53 percent) and 349 (47 percent) were performed at the community hospital. Categories of free tissue transfer reconstruction included breast, lower extremity, head and neck, and upper extremity reconstructions. Most of the breast reconstructions were performed in the community hospital, whereas most of the lower extremity and head and neck reconstructions were performed at the university hospital. Fifty-one major postoperative complications occurred in the university hospital (14 percent), while 31 (10 percent) occurred in the community hospital. Complication rates did not differ significantly between settings; however, there was a trend toward more wound infections in the university hospital and more cases of fat necrosis in the community hospital, most likely reflected in the differing case mix between hospital settings. CONCLUSION: Free tissue transfer is an effective and practical method of reconstruction that has been safely performed in both university and community hospital settings.

Academic Medical Centers↗