Abstract 9152: Incidence of Cardiac Arrest Among Medicare Beneficiaries

Introduction: Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last two decades, survival rates have plateaued in recent years. Our understanding of incidence of IHCA remains limited. We measured incidence of IHCA among Medicare beneficiaries and evaluated hospital variation in incidence of IHCA. Methods: We used an observational cohort study using data from 2014-2017 Get with the Guidelines-Resuscitation (GWTG-R) data linked with Medicare inpatient data summarized by hospital. Hospital incidence of IHCA among Medicare beneficiaries was calculated as the total number of patients 65 years and older with an IHCA divided by the total number of Medicare admissions. Multivariable hierarchical regression models were used to adjust hospital incidence rates for differences in case-mix across study hospitals and evaluate its the association with hospital variables. Results: Among a total of 4.5 million admissions at 170 hospitals, 38,630 patients experienced an IHCA. The median risk-adjusted IHCA incidence was 8.3 per-1000 admissions. Even after adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals (Figure 1) ranging from 2.1 per-1000 admissions to 24.7 per-1000 admissions (interquartile range: 6.5-11.4; median odds ratio: 1.52; 95% credible interval 1.45-1.59). Among hospital variables, a higher case-mix index, higher nurse staffing and teaching status were associated with a lower hospital incidence of IHCA. Conclusions: Incidence of IHCA varies markedly across hospitals, even after adjustment for differences in patient case-mix. Hospital variables including case-mix severity, nurse staffing and teaching status were significantly associated with incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Examining Adverse Patient Outcomes in Nurses: The Role of Patient Acuity, Shift and Fatigue

This study identified key factors contributing to adverse patient outcomes (APOs) at a mid-western hospital. Understanding risk factors that contribute to increased nurse fatigue can provide solutions to reduce the impact that fatigue has on nurse performance and patient outcome. This study was comprised of two phases: 1) a database analysis of current data collected at a mid-western hospital, and 2) three focus groups to identify nurse perceptions pertaining to task demand and fatigue. The APOs analyzed in this study were medical administration errors (MAEs) and patient falls. A comparison of the data from both phases was then conducted to determine whether data reflected in the database correlated with nurse perceptions. This analysis documents significant results with respect to APOs in the following workload factors such as: hours worked, case mix index (CMI), shift, and nursing unit type.

Cost–DALY comparison of hip replacement care in 12 Belgian hospitals

BackgroundIn view of the expected increase in expenditure on hip replacement treatment in Belgium, the complication rate and potential waste reduction, as estimated by the Organisation for Economic Cooperation and Development, we are not yet in a position to assess the efficiency of hip replacement treatment in Belgian hospitals. This objective study uses a cost–disability-adjusted life years (DALYs) ratio to propose a comparison of hip replacement surgery among 12 Belgian hospitals.MethodsOur study seeks to innovate by proposing an interhospital comparison that simultaneously integrates the weighting of quality indicators and the costs of managing a patient. To this end, we associated a DALY impact with each patient safety indicator, readmission and mortality outcome. We then compared hospitals using both costs and DALYs adjusted to their case mix index. The adjusted values (costs and DALYs) were obtained by relating the observed value to the predicted value obtained from the linear regression model.ResultsWe registered a total of 246.5 DALYs for the 12 hospital institutions, the average cost (SD) of a stay being €8013 (€4304). Our model allowed us to identify hospitals with observed values higher than those predicted. Out of the 12 hospitals evaluated, 4 need to reduce costs and DALYs impacts, 6 have to improve one of the two factors and 2 appear to have good results. The costs for the worst performing hospitals can rise to over €150 000.ConclusionEvaluating the rates of patient safety indicators, associated with cost, is a prerequisite for quality and cost improvement efforts on the part of managers and practitioners. However, it appears essential to evaluate the entire care chain using a comparable unit of measurement. The hospital’s case mix index must also be considered in benchmarking to avoid drawing the wrong conclusions. In addition, other indicators, such as the patient’s perception of the actual results, should be added to our study.

Early prediction of diagnostic-related groups and estimation of hospital cost by processing clinical notes

As healthcare providers receive fixed amounts of reimbursement for given services under DRG (Diagnosis-Related Groups) payment, DRG codes are valuable for cost monitoring and resource allocation. However, coding is typically performed retrospectively post-discharge. We seek to predict DRGs and DRG-based case mix index (CMI) at early inpatient admission using routine clinical text to estimate hospital cost in an acute setting. We examined a deep learning-based natural language processing (NLP) model to automatically predict per-episode DRGs and corresponding cost-reflecting weights on two cohorts (paid under Medicare Severity (MS) DRG or All Patient Refined (APR) DRG), without human coding efforts. It achieved macro-averaged area under the receiver operating characteristic curve (AUC) scores of 0·871 (SD 0·011) on MS-DRG and 0·884 (0·003) on APR-DRG in fivefold cross-validation experiments on the first day of ICU admission. When extended to simulated patient populations to estimate average cost-reflecting weights, the model increased its accuracy over time and obtained absolute CMI error of 2·40 (1·07%) and 12·79% (2·31%), respectively on the first day. As the model could adapt to variations in admission time, cohort size, and requires no extra manual coding efforts, it shows potential to help estimating costs for active patients to support better operational decision-making in hospitals.

Improved efficiency of coding systems with health information technology

This study aimed to investigate the impact of health information technology (IT) on the Case Mix Index (CMI). This study was a retrospective cohort study using hospital financial data from the Office of Statewide Health Planning and Development (OSHPD) in California. A total of 309 unique hospitals were included in the study for 7 years, from 2009 to 2015, resulting in 2,135 hospital observations. The effects of health information technology (IT) on the Case Mix Index (CMI) was evaluated using dynamic panel data analysis to control endogeneity issues. This study found that more health IT adoption could lead to a lower CMI by improving coding systems. Policy makers, researchers, and healthcare providers must be cautious when interpreting the effect of health IT on the CMI. To encourage the adoption of health IT, the cost savings and reimbursement reductions resulting from health IT adoption should be compared. If any profit loss occurs (i.e., the cost savings is less than reimbursement reduction), more incentives should be provided to healthcare providers.

Impact of quality certification of multidisciplinary head and neck tumor centers

Background Certification of multidisciplinary tumor centers is nowadays seen as the gold standard in modern oncological therapy for optimization and realization of guideline-based therapy and better outcomes. Single cases are reimbursed based on diagnosis-related groups (DRG). We aimed to review efficiency, cost analysis, and profitability following a certification. Methods Tumor board certification at the university hospital Aachen was implemented in 2013. We compared 1251 cases of oropharyngeal cancer treated from 2008 to 2017 before and after certification. For this purpose, several patient characteristics, surgery, and stay-related constants, as well as expenses and reimbursement heights were analyzed statistically. Results Following certification, the total case and patient number, surgery duration, hours of mechanical ventilation, case mix index points, DRG reimbursements as well as the costs increased significantly, whereas days of intensive care unit, amount of blood transfusions, patient clinical complexity level (PCCL) and the overall stay were significantly lowered. No changes were observed for the patient’s age and gender distribution. Also, the predetermined stay duration stayed constant. Conclusions Certification of head-neck tumor centers causes a concentration of more complex cases requiring higher surgical efforts, which can be processed more efficiently due to a higher level of professionalism. Despite their benefits in cancer care, without compensation, centers may be struggling to cover their expenses in a system, which continuously underestimates them.

Area-based Network of Health Workers to Mitigate the Shortage of Health Workforce: A Case Mix Index Approach for Thailand

BackgroundPublic hospitals under the Office of Permanent Secretary, Ministry of Public Health have critical shortage in health workers. The area-based network consolidations of public hospitals should help to enhance capacity of the health system from allocation improvement in limited resources.MethodsThis study calculates the counterfactual simulations of area-based network allocations for health workforce in 10,500 public hospitals. The network consolidations at the sub-district, district, provincial, or health-region levels allow health workforce reallocation within local network areas. This study examines improvements in the allocative efficiency from the health workforce redistribution. The workload per worker is calculated from the output measured by numbers of outpatient and inpatient cases and the input measured by numbers of health workers. Both output and input are weighted with their economic values, controlled for heterogeneity by regression analysis. The weights assigned to each outpatient and inpatient case reflect the relative health system resources predicted for each discharge. Finally, this study compares the status quo and ex ante scenarios, as before and after network consolidations.ResultsNetwork consolidations of the primary-level hospitals within the same district could averagely reduce workload per worker by 14%. Another practical policy option is that consolidating similar hospital levels such as primary, first-level secondary, and mid-level secondary hospitals altogether within the same district could reduce the workload per worker by 17%.ConclusionThis study illustrates improvement in allocative efficiency of health workforce in public hospitals from the area-based network consolidations. The results provide an insightful example of efficiency gains from reallocating medical workforce within the same local areas.

Assoziation von Strukturvariablen mit der Versorgungsqualität der Krankenhäuser in Deutschland

Zusammenfassung Hintergrund Die deutsche Krankenhauslandschaft befindet sich finanzierungsbedingt in einem unkoordinierten Strukturwandel. Gleichzeitig wird versucht, mithilfe von qualitätsorientierten Steuerungsmaßnahmen die Behandlungsqualität sicherzustellen und zu verbessern. Unklar ist, ob insgesamt die richtigen Strukturen erhalten bleiben, also diejenigen, die bislang Garant positiver Ergebnisse sind. Ziel Untersuchung der Assoziation verschiedener Strukturmerkmale von Krankenhäusern mit der Versorgungsqualität. Methode In einer Sekundärdatenanalyse wurde auf Basis von Krankenhaus-Qualitätsberichten die Assoziation zwischen der Versorgungsqualität und den Strukturmerkmalen Krankenhausgröße, Art der Trägerschaft, Region, Lehrstatus und Case-Mix-Index (CMI) verglichen. Dazu wurden anhand ausgewählter Qualitätsindikatoren der externen Qualitätssicherung (eQS) für jedes Krankenhaus Qualitätsindices berechnet und zunächst univariat mittels Mann-Whitney-U-Test bzw. Kruskal-Wallis-Test sowie anschließend mittels multipler linearer Regressionsanalyse die Assoziationen unter Berücksichtigung der Interaktionseffekte der unabhängigen Variablen untersucht. Ergebnisse Bei ca. 90% der geprüften Indices lagen signifikante Assoziationen zwischen den Strukturmerkmalen und der Versorgungsqualität vor. Positive Assoziationen mit der Versorgungsqualität lagen bei den Strukturmerkmalen Krankenhausgröße von weniger als 100 Betten, private Trägerschaft, kein Lehrkrankenhaus und geringer CMI vor. Negative Tendenzen lagen v. a. bei den Strukturvariablen Krankenhausgröße von mehr als 500 Betten, öffentliche Trägerschaft, Lehrkrankenhaus und bei höherem CMI vor. Schlussfolgerung Den Ergebnissen dieser Studie zufolge scheinen kleine Krankenhäuser die beste Versorgungsqualität zu erbringen. Dieses kontraintuitive Ergebnis deutet darauf hin, dass die bei der Indexberechnung einbezogenen Qualitätsindikatoren der eQS eventuell unzureichend risikoadjustiert bzw. wissenschaftlich evaluiert sind, sodass von deren Verwendung als Instrumente zur Qualitätssteuerung abzuraten ist.

10 Jahre Handtraumatologie – eine epidemiologische, strukturelle und ökonomische Standortanalyse an einem Krankenhaus der Maximalversorgung

Zusammenfassung Hintergrund Die handchirurgische Versorgung in Deutschland unterliegt einem Strukturwandel, der viele Abteilungen in ein Spannungsfeld zwischen Medizin und Ökonomie bringt. Einerseits kommt es zu einer Umverteilung elektiver handchirurgischer Eingriffe aus dem stationären in den ambulanten Sektor, andererseits konzentrieren sich – so unser Eindruck – stationär zu behandelnde handchirurgische Notfälle mehr und mehr an großen Kliniken. Vor diesem Hintergrund fehlen Daten zur Versorgungsrealität von handchirurgischen Notfällen, die diese Arbeit durch eine 10-Jahresanalyse handtraumatologischer Fälle unter epidemiologischen, strukturellen und ökonomischen Aspekten an einer Klinik der Maximalversorgung erhebt und zur Diskussion stellt. Material und Methoden Anhand einer Datenbankabfrage über ICD-Codes wurden handtraumatologische (Hauptdiagnose), stationär behandelte Fälle zwischen 2009 und 2018 identifiziert und im Hinblick auf epidemiologische und wirtschaftliche Kennzahlen (Alter, Geschlecht, Komorbiditäten, Case-Mix-Index, Erlös, Verweildauern, OP-Zeiten) unter verschiedenen Aspekten über PIVOT-Tabellen analysiert. Ausgeschlossen wurden Patienten unter 16 Jahren, Unterarmfrakturen sowie intensivmedizinische Patienten. Ergebnisse Im untersuchten Zeitraum und Zentrum war der typische handchirurgische Traumapatient männlich und durchschnittlich 44 Jahre alt. Der Patient Clinical Complexity Level war in 80 % aller Fälle 0. Der Anteil an Arbeitsunfällen lag durchschnittlich bei ca. 25 %. Die 3 Top-DRGs waren die I32F (18,5 %), X01B (11,3 %) sowie die I32A (7,2 %). Auffällig war über die Jahre ein massiver Fallzahlanstieg von ca. 300 auf über 1000 Fälle/Jahr. Gleichzeitig wurde die Versorgung handchirurgischer Notfälle in 4 von 5 anderen Kliniken in einem Umkreis von 100 km zurückgefahren. Insbesondere außerhalb der Kernarbeitszeit kam es hierdurch zu einer Mehrbelastung. Die mittlere Verweildauer lag bei ca. 4–5 Tagen, die durchschnittliche Schnitt-Naht-Zeit unter 60 Minuten und der durchschnittliche CMI bei 1,23. Damit erlösten diese Patienten im Jahr 2018 4370 €, wobei die BG-Erlöse durchschnittlich 387 € niedriger lagen. Schlussfolgerung Ausgehend von einer höchstwahrscheinlich mehr oder weniger gleichgebliebenen Zahl handchirurgischer Notfälle führen wir den deutlichen Fallzahlanstieg in der Handtraumatologie in unserer Klinik nicht auf eine Zunahme der Verletzungen zurück, sondern auf eine zunehmende Konzentration dieser Fälle in wenigen handchirurgischen Zentren, da aus wirtschaftlichen Gründen die Versorgung von Notfällen an kleineren Häusern zunehmend reduziert wird und dies, obwohl unter wirtschaftlichen Aspekten Handverletzungen interessant sind; lassen sich doch mit wenig Aufwand verhältnismäßig gute Erlöse erzielen, die bei Überschreiten einer kritischen Patientenzahl die Vorhaltekosten einer Dienst-Versorgung amortisieren. Dort, wo sich die Versorgung handtraumatologischer Fälle konzentriert, kommt es insbesondere außerhalb der Kernarbeitszeit zu einer Mehrbelastung, unter Umständen mit negativen Auswirkungen auf die elektive Handchirurgie.