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Safavi K.C.,Yale University | Li S.-X.,Center for Outcomes Research and Evaluation | Li S.-X.,Yale University | Dharmarajan K.,Center for Outcomes Research and Evaluation | And 12 more authors.
JAMA Internal Medicine | Year: 2014

Design, Setting, and Participants Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease.We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549 078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8%(10.9%-27.7%); range, 0.2%to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2%vs Q4, 4.9%), and revascularization procedures (Q1, 0.5%vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6%vs Q4, 5.4%) and for angiograms (Q1, 41.2%vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P=.51). Approximately 23%of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography. Copyright © 2014 American Medical Association. All rights reserved.

Doubeni C.A.,University of Massachusetts Medical School | Jambaulikar G.D.,University of Massachusetts Medical School | Fouayzi H.,University of Massachusetts Medical School | Robinson S.B.,Premier Inc | And 4 more authors.
PLoS ONE | Year: 2012

Background: Low-socioeconomic status (SES) is associated with a higher colorectal cancer (CRC) incidence and mortality. Screening with colonoscopy, the most commonly used test in the US, has been shown to reduce the risk of death from CRC. This study examined if, among insured persons receiving care in integrated healthcare delivery systems, differences exist in colonoscopy use according to neighborhood SES. Methods: We assembled a retrospective cohort of 100,566 men and women, 50-74 years old, who had been enrolled in one of three US health plans for ≥1 year on January 1, 2000. Subjects were followed until the date of first colonoscopy, date of disenrollment from the health plan, or December 31, 2007, whichever occurred first. We obtained data on colonoscopy use from administrative records. We defined screening colonoscopy as an examination that was not preceded by gastrointestinal conditions in the prior 6-month period. Neighborhood SES was measured using the percentage of households in each subject's census-tract with an income below 1999 federal poverty levels based on 2000 US census data. Analyses, adjusted for demographics and comorbidity index, were performed using Weibull regression models. Results: The average age of the cohort was 60 years and 52.7% were female. During 449,738 person-years of follow-up, fewer subjects in the lowest SES quartile (Q1) compared to the highest quartile (Q4) had any colonoscopy (26.7% vs. 37.1%) or a screening colonoscopy (7.6% vs. 13.3%). In regression analyses, compared to Q4, subjects in Q1 were 16% (adjusted HR = 0.84, 95% CI: 0.80-0.88) less likely to undergo any colonoscopy and 30%(adjusted HR = 0.70, CI: 0.65-0.75) less likely to undergo a screening colonoscopy. Conclusion: People in lower-SES neighborhoods are less likely to undergo a colonoscopy, even among insured subjects receiving care in integrated healthcare systems. Removing health insurance barriers alone is unlikely to eliminate disparities in colonoscopy use. © 2012 Doubeni et al.

Shaw A.D.,Duke University | Bagshaw S.M.,University of Alberta | Goldstein S.L.,Cincinnati Childrens Hospital | Scherer L.A.,University of California at Davis | And 3 more authors.
Annals of Surgery | Year: 2012

Objective: To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. Background: 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. Methods: An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. RESULTS:: For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66-0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. Conclusions: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline. © 2012 by Lippincott Williams & Wilkins.

Delaney C.P.,Case Western Reserve University | Craver C.,Premier Inc | Gibbons M.M.,View Medical | Rachfal A.W.,Adolor Corporation | And 5 more authors.
Annals of Surgery | Year: 2012

Objective: To evaluate in-hospital clinical outcomes after open and laparoscopic bowel resection (BR) with or without alvimopan treatment. Background: Delayed return of gastrointestinal function after BR may be associated with greater postoperative morbidity and increased hospital length of stay (LOS). In clinical trials, alvimopan-a peripherally acting μ-opioid receptor antagonist-accelerated gastrointestinal recovery after open BR. Methods: A retrospective matched-cohort study (NCT01150760) was conducted using a national inpatient database. Each alvimopan patient was exact matched (surgical procedure, surgeon specialty) and propensity score matched (baseline characteristics) to a nonalvimopan BR patient. Outcomes included gastrointestinal and other morbidity (cardiovascular, pulmonary, infection, cerebrovascular, thromboembolic); mortality; readmission rate; and intensive care unit (ICU) stay (intent-to-treat [ITT] population). Postoperative LOS and estimated cost were also compared (modified ITT population). Results: Each cohort included 3525 ITT patients with similar baseline characteristics. Gastrointestinal (29.8% vs 35.7%) and other morbidity (cardiovascular [19.4% vs 24.0%], pulmonary [7.3% vs 10.5%], infectious [9.6% vs 11.8%], thromboembolic [1.2% vs 2.1%]), mortality (0.4% vs 1.0%), and mean ICU stay (0.3 vs 0.6 days) were lower in the alvimopan group (P ≤ 0.003 for each). Postoperative LOS and estimated direct cost were lower for all alvimopan patients and after laparoscopic and open BR (LOS:-1.1,-0.8, and-1.8 days respectively; cost:-$2345,-$1382, and-$3218, respectively; P ≤ 0.0008 for each). Conclusions: On average, alvimopan-treated patients had a lower incidence of mortality and most incidents of morbidities. Length of stay, ICU use, and estimated cost were also lower with comparable readmissions. These results in patients outside the clinical trial setting include laparoscopic colectomy and demonstrate a potential association between acceleration of gastrointestinal recovery and improved early postoperative outcomes. © 2012 Lippincott Williams & Wilkins.

Kroch E.A.,Premier Inc | Johnson M.,University of Pennsylvania | Martin J.,Mercy Health Center | Duan M.,Mercy Health Center
American Journal of Medical Quality | Year: 2010

Accounting for patients admitted to hospitals at the end of a terminal disease process is key to signaling care quality and identifying opportunities for improvement. This study evaluates the benefits and caveats of incorporating care-limiting orders, such as do not resuscitate (DNR) and palliative care (PC) information, in a general multivariate model of mortality risk, wherein the unit of observation is the patient hospital encounter. In a model of the mortality gap (observed - expected from the baseline model), DNR explains 8% to 24% of the gap variation. PC provides additional explanatory power to some disease groupings, especially heart and digestive diseases. One caveat is that DNR information, especially if associated with the later stages of hospital care, may mask opportunities to improve care for certain types of patients. But that is not a danger for PC, which is unequivocally valuable in accounting for patient risk, especially for certain subpopulations and disease groupings. © 2010 by the American College of Medical Quality.

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