case mix
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2022 ◽  
pp. emermed-2020-210628
Author(s):  
Bart GJ Candel ◽  
Renée Duijzer ◽  
Menno I Gaakeer ◽  
Ewoud ter Avest ◽  
Özcan Sir ◽  
...  

BackgroundAppropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category.AimsTo assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories.MethodsObservational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81–100, 101–120, 121–140, >140 mm Hg).ResultsWe included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients.ConclusionFor SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.


2022 ◽  
Vol 23 (1) ◽  
Author(s):  
Joao A. de Andrade ◽  
Tejaswini Kulkarni ◽  
Megan L. Neely ◽  
Anne S. Hellkamp ◽  
Amy Hajari Case ◽  
...  

Abstract Background Performance benchmarks for the management of idiopathic pulmonary fibrosis (IPF) have not been established. We used data from the IPF-PRO Registry, an observational registry of patients with IPF managed at sites across the US, to examine associations between the characteristics of the enrolling sites and patient outcomes. Methods An online survey was used to collect information on the resources, operations, and self-assessment practices of IPF-PRO Registry sites that enrolled ≥ 10 patients. Site variability in 1-year event rates of clinically relevant outcomes, including death, death or lung transplant, and hospitalization, was assessed. Models were adjusted for differences in patient case mix by adjusting for known predictors of each outcome. We assessed whether site-level heterogeneity existed for each patient-level outcome, and if so, we investigated potential drivers of the heterogeneity. Results All 27 sites that enrolled ≥ 10 patients returned the questionnaire. Most sites were actively following > 100 patients with IPF (70.4%), had a lung transplant program (66.7%), and had a dedicated ILD nurse leader (77.8%). Substantial heterogeneity was observed in the event rates of clinically relevant outcomes across the sites. After controlling for patient case mix, there were no outcomes for which the site variance component was significantly different from 0, but the p-value for hospitalization was 0.052. Starting/completing an ILD-related quality improvement project in the previous 2 years was associated with a lower risk of hospitalization (HR 0.60 [95% CI 0.44, 0.82]; p = 0.001). Conclusions Analyses of data from patients with IPF managed at sites across the US found no site-specific characteristics or practices that were significantly associated with clinically relevant outcomes after adjusting for patient case mix. Trial registration ClinicalTrials.gov, NCT01915511. Registered 5 August 2013, https://clinicaltrials.gov/ct2/show/NCT01915511


2021 ◽  
pp. 219256822110648
Author(s):  
Juliëtte J. C. M. Van Munster ◽  
Vera de Weerdt ◽  
Ilan J. Y. Halperin ◽  
Amir H. Zamanipoor Najafabadi ◽  
Peter Paul G. van Benthem ◽  
...  

Study Design Literature review. Objective To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time. Methods Literature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman’s rho was used to determine the association between the Extreme Quotient (EQ) and year of publication. Results We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= −.33, P= .09). Conclusions Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.


Author(s):  
Hirotaka Sakai ◽  
Mitsunaga Iwata ◽  
Teruhiko Terasawa

Abstract The Michigan peripherally inserted central catheter–associated bloodstream infection score (MPC score) had been developed for hospitalized medical patients but had not been externally validated. A retrospective analysis of a clinically heterogeneous case-mix in a university hospital cohort in Japan failed to validate its originally reported good performance.


2021 ◽  
Author(s):  
Hessam Bavafa ◽  
Lerzan Örmeci ◽  
Sergei Savin ◽  
Vanitha Virudachalam

How to Assess the Benefits of Coordination in Managing Hospital Resources In providing patient care, hospitals rely on multiple types of resources, such as operating rooms, recovery beds, labs, and diagnostic equipment, that are often controlled and managed as separate entities and by different decision makers. In “Surgical Case-Mix and Discharge Decisions: Does Within-Hospital Coordination Matter?” Hessam Bavafa, Lerzan Örmeci, Sergei Savin, and Vanitha Virudachalam focus on the interaction between “front-end’’ resources, such as operating rooms, and “backroom’’ resources, such as recovery beds, and compare hospital profitability under the fully coordinated, optimal approach to hospital resource management and under alternative decentralized approaches often encountered in practice. The paper identifies settings in which the benefits of coordination are likely to be high as well as settings in which those benefits are at best moderate. In a given hospital, only hospital managers are in a position to estimate with any degree of certainty potential costs of coordinated management of hospital resources, and the paper’s analysis of the benefits of coordination empowers hospital managers to make informed decisions on the desirability of replacing the often decentralized “status quo” by centralized resource management.


Author(s):  
William A Bryant ◽  
Richard W Issitt ◽  
Lydia Briggs ◽  
Daniel Key ◽  
John Booth ◽  
...  
Keyword(s):  
Case Mix ◽  

Author(s):  
Jacob A. Doll ◽  
Adam J. Nelson ◽  
Lisa A. Kaltenbach ◽  
Daniel Wojdyla ◽  
Stephen W. Waldo ◽  
...  

Background: Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. Methods: Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. Results: We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment–elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, −0.03 [95% CI, −0.10 to 0.04]), higher for cluster 3 (0.14 [0.07–0.22]), and lower for cluster 4 (−0.15 [−0.24 to −0.06]). Conclusions: Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.


2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 71-71
Author(s):  
Nicholas Castle ◽  
John Harris ◽  
David Wolf

Abstract Nursing home satisfaction information has gained substantial traction as a quality indicator representing the consumers perspective. However, very little research has examined differences in satisfaction related to race, age and gender. As a quality metric, satisfaction measures are variously used for quality improvement, benchmarking, public reporting, and for adjustment to payments. As such, valid comparisons among facilities are important. To our knowledge, no adjustment to satisfaction scores are currently used for nursing homes. However, in many other settings this is a common practice. In this research, nursing home resident, family, and discharge satisfaction scores were examined from &gt;4,000 participants. The data were collected in 2020 and come from 420 facilities. Satisfaction information came from the CoreQ surveys, which include 23 individual questions four of which can be combined to produce an overall satisfaction score. These CoreQ nursing home surveys are endorsed by NQF. Generally lower overall satisfaction scores were found for family members compared to current residents or discharged residents. Minorities (Black, Asian, Hispanic) had lower overall satisfaction scores compared to whites; however, the differences were not significant at conventional levels. Participants of the lowest age (&lt;65 years) were significantly (p=&lt;.05) less satisfied than older participants (&gt;75 years) and males were significantly (p=&lt;.05) less satisfied than females. The findings indicate that some case-mix adjustment may be applicable for nursing home satisfaction scores.


2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 528-528
Author(s):  
Lindsey Smith ◽  
Wenhan Zhang ◽  
Sheryl Zimmerman ◽  
Philip Sloane ◽  
Kali Thomas ◽  
...  

Abstract State agencies regulate assisted living (AL) with varying approaches across and within states. The implications of this variation for resident case mix, health service use, and policy, are not well described. We collected health services-relevant AL regulatory requirements for all 50 states and DC and used a mixed-methods approach (thematic analysis; k-means cluster analysis) to identify six types: Housing, Affordable, Hybrid, Hospitality, Healthcare, and Hybrid-Healthcare. We stratified Medicare claims data by regulatory type, identifying variation in resident case mix and health service use. Housing and Affordable clusters have larger proportions of dual-eligible beneficiaries, Black residents, and residents of Affordable had more long-term nursing home use compared to other clusters. Dual-eligible beneficiaries account for 26.6% of Housing cluster residents compared to 8.1% of Hybrid Healthcare cluster residents. We provide other examples and explain the implications in terms of sampling AL for single and multi-state studies, racial disparities, and health-related policies.


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