The Effect of Preexisting Conditions on Hospital Quality Measurement for Injured Patients
ABSTRACT To determine whether adjusting for comorbidities significantly affects hospital quality measurement compared with adjusting for injury severity alone.
Pre-existing conditions have a significant impact on mortality after injury. The impact of including comorbidities on hospital quality measurement is not well understood.
Retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (2005-2006). The Trauma Mortality Probability Model (TMPM-ICD9) was re-estimated with and without the addition of the comorbidity measures in the Agency for Health Research and Quality comorbidity algorithm. Hospital quality was measured using an adjusted odds ratio (OR) obtained using hierarchical logistic regression modeling. The OR quantifies the likelihood that trauma patients treated at a specific hospital are more or less likely to die compared with patients treated at an average hospital. Hospitals with an adjusted OR significantly greater than, or less than 1 were classified as low-quality or high-quality outliers, respectively. Pairwise comparison of hospital quality based on TMPM-ICD9 with and without comorbidity information were performed using the intraclass correlation coefficient, the Spearman correlation coefficient, the Bland-Altman Plot, and the kappa statistic.
There was nearly perfect agreement between hospital ranking based on TMPM-ICD9 and TMPM-ICD9 with comorbidities. The intraclass correlation coefficient was 0.943 (95% CI, 0.931-0.951), the Spearman correlation coefficient was 0.953 (95% CI, 0.944-0.960), and the kappa statistic was 0.863 (95% CI, 0.792-0.934). The odds of a patient dying in the worst 5% hospitals was 1.73 (95% CI, 1.61-1.86), whereas the odds of a patient dying in the best 5% of the hospitals was 0.37 (95% CI, 0.31-0.44).
In this large study of 148,280 trauma patients in 511 hospitals, we found no evidence that adding comorbidites to the risk-adjustment model used to benchmark hospital performance changes hospital ranking. In addition, there appears to be significant variability in mortality outcomes between the best and worst performing hospitals. This difference in outcomes across hospitals may represent a significant opportunity to improve health outcomes for injured patients.
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ABSTRACT: IMPORTANCE An Institute of Medicine report on patient safety that cited medical errors as the 8th leading cause of death fueled demand to use quality measurement as a catalyst for improving health care quality. OBJECTIVE To determine whether providing hospitals with benchmarking information on their risk-adjusted trauma mortality outcomes will decrease mortality in trauma patients. DESIGN, SETTING, AND PARTICIPANTS Hospitals were provided confidential reports of their trauma risk-adjusted mortality rates using data from the National Trauma Data Bank. Regression discontinuity modeling was used to examine the impact of nonpublic reporting on in-hospital mortality in a cohort of 326 206 trauma patients admitted to 44 hospitals, controlling for injury severity, patient case mix, hospital effects, and preexisting time trends. MAIN OUTCOMES AND MEASURES In-hospital mortality rates. RESULTS Performance benchmarking was not significantly associated with lower in-hospital mortality (adjusted odds ratio [AOR], 0.89; 95% CI, 0.68-1.16; P = .39). Similar results were obtained in secondary analyses after stratifying patients by mechanism of trauma: blunt trauma (AOR, 0.91; 95% CI, 0.69-1.20; P = .51) and penetrating trauma (AOR, 0.75; 95% CI, 0.44-1.28; P = .29). We also did not find a significant association between nonpublic reporting and in-hospital mortality in either low-risk (AOR, 0.84; 95% CI, 0.57-1.25; P = .40) or high-risk (AOR, 0.88; 95% CI, 0.67-1.17; P = .38) patients. CONCLUSIONS AND RELEVANCE Nonpublic reporting of hospital risk-adjusted mortality rates does not lead to improved trauma mortality outcomes. The findings of this study may prove useful to the American College of Surgeons as it moves ahead to further develop and expand its national trauma benchmarking program.JAMA SURGERY 12/2013; 149(2). DOI:10.1001/jamasurg.2013.3977 · 4.30 Impact Factor
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ABSTRACT: Objective To determine whether outcome disparities between black and white trauma patients have decreased over the last 10years. Data SourcePennsylvania Trauma Outcome Study. Study DesignWe performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure-to-rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals. Principal FindingsTrauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09-1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42-2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54-0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60-0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10years. Conclusion Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites.Health Services Research 05/2013; 48(5). DOI:10.1111/1475-6773.12064 · 2.49 Impact Factor
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ABSTRACT: The enormous fiscal pressures facing trauma centers may lead trauma centers to reduce nurse staffing and to make increased use of less expensive and less skilled personnel. The impact of nurse staffing and skill mix on trauma outcomes has not been previously reported. The goal of this study was to examine whether nurse staffing levels and nursing skill mix are associated with trauma patient outcomes. We used data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to perform a cross-sectional study of 70,142 patients admitted to 77 Level I and Level II centers. Logistic regression models were used to examine the association between nurse staffing measures and (1) mortality, (2) healthcare associated infections (HAI), and (3) failure-to-rescue. We controlled for patient risk factors (age, gender, injury severity, mechanism of injury, comorbidities) and hospital structural characteristics (trauma center status - Level I versus Level II, hospital size, ownership, teaching status, technology level, and geographic region). A 1% increase in the ratio of licensed practical nurse (LPN) to total nursing time was associated with a 4% increase in the odds of mortality (adj OR 1.04; 95% CI: 1.02-1.06; p = 0.001) and a 6% increase in the odds of sepsis (adj OR 1.06: 1.03-1.10; p < 0.001). Hospitals in the highest quartile of LPN staffing had 3 excess deaths (95% CI: 1.2, 5.1) and 5 more episodes of sepsis (95% CI: 2.3, 7.6) per 1000 patients compared to hospitals in the lower quartile of LPN staffing. Higher hospital LPN staffing levels are independently associated with slightly higher rates of mortality and sepsis in trauma patients admitted to Level I or Level II trauma centers.BMC Health Services Research 08/2012; 12:247. DOI:10.1186/1472-6963-12-247 · 1.66 Impact Factor