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Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

ABSTRACT: Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery.We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n?=?294) and those who did accept ABT (control, n?=?1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis.Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p?=?0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p?=?0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8?±?2.7?g/dL) and control (10.9?±?2.3?g/dL) groups (p?=?0.42). Total and direct hospital costs were 12% (p?=?0.02) and 18% (p?=?0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup.Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

SUBMITTER: Frank SM

PROVIDER: S-EPMC4234090 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

Frank Steven M SM Wick Elizabeth C EC Dezern Amy E AE Ness Paul M PM Wasey Jack O JO Pippa Andrew C AC Dackiw Elizabeth E Resar Linda M S LM

Transfusion 20140618 10 Pt 2

<h4>Background</h4>Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery.<h4>Study design and methods</h4>We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multi ...[more]

PMID: 24942198

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Project description:It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.We studied the risk-adjusted outcomes of 6 medical conditions during the inpatient and 90-day post-discharge period to identify the opportunities for care improvement. The Medicare Limited Dataset for 2012 to 2014 was used to identify acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia (PNEU), cerebrovascular accidents (CVA), and gastrointestinal hemorrhage (GIH). Stepwise logistic predictive models were developed for the adverse outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths, and 90-day readmissions after unrelated events were excluded. Observed and predicted AOs were determined for each hospital with ?75 cases for each of the 6 medical conditions. Z-scores and risk-adjusted AO rates for each hospital permitted comparative analysis of outcomes after adjusting for covariance among the medical conditions.There were a total of 1,811,749 patients from 973 acute care hospitals with the 6 medical conditions. A total of 41% of all patients had ?1 AO events. One or more readmissions were identified in 29.8% of patients. A total of 64 hospitals (6.4%) were 2 standard deviations better than the mean for risk-adjusted outcomes, and 72 (7.4%) were 2 standard deviations poorer. The best performing decile of hospitals had mean AO rates of 35.1% (odds ratio?=?0.766; 95% confidence interval (CI) CI: 0.762-0.771) and the poorest performing decile a mean AO rate of 48.5% (odds ratio?=?1.357; 95% CI: 1.346-1.369). Volume of qualifying cases ranged from 670 to 9314; no association was identified for increased volume of patients (P?<?.40).Risk-adjusted AO rates demonstrated nearly a 14% opportunity for care improvement between top and suboptimal performing hospitals. Hospitals must be able to benchmark objective measurement of outcomes to inform quality initiatives.

Project description:The circumferential resection margin is the primary determinant of local recurrence and a major factor in survival in rectal cancer. Neither chemotherapy nor chemoradiation compensates for a margin positive for cancer.To identify treatment-related factors associated with hospital margin-positive resection and to develop a tool that could be used by individual hospitals to assess their outcomes based on their unique mix of patient and tumor characteristics.Retrospective review of the National Cancer Data Base, 1998-2007.Community and academic/research hospitals.Individuals with histologically confirmed localized rectal/rectosigmoid adenocarcinoma.All individuals underwent radical resection for rectal cancer with or without neoadjuvant therapy.Rate of margin positivity determined and adjusted for patient- and tumor-related factors to calculate expected margin positivity per hospital. An observed to expected ratio was calculated based on patient- and tumor-related factors to identify treatment-associated variation.The overall margin-positive resection rate was 5.2%. Patients with margins positive for cancer were more likely to be older, male, and African American; not have private insurance; and have their cancer diagnosed later in the study period. Associated tumor-related factors include rectal location, higher American Joint Committee on Cancer stage, signet/mucinous histology, and poor/undifferentiated grade. Among hospitals that were significantly low outliers, 47% were comprehensive community hospitals, and 43.9% were academic/research hospitals; of those that were significantly high outliers, 52.3% were comprehensive community hospitals, and 17.8% were academic/research hospitals. High-volume centers made up 80% of significantly low outlier hospitals and 17% of significantly high outlier hospitals. The rates of chemotherapy and radiation were similar, but low outlier hospitals gave more neoadjuvant radiation (26.3% vs 17%).After adjustment for patient- and tumor-related factors, we identified both low and high outlier hospitals for margin positivity at resection, as well as potentially modifiable risk factors. The nomogram created in this model allows for the evaluation of observed and expected event rates for individual hospitals, providing a hospital self-assessment tool for identifying targets for improvement.

Project description:RATIONALE:There remains significant controversy regarding the optimal approach to fluid resuscitation for patients in shock. The magnitude of care variability in shock resuscitation, the confounding effects of disease severity and comorbidity, and the relative impact on sepsis survival are poorly understood. OBJECTIVE:To evaluate usual care variability and determine the differential effect of observed and predicted fluid resuscitation volumes on risk-adjusted hospital mortality for mechanically ventilated patients in shock. METHODS:We performed a retrospective outcome analysis of mechanically ventilated patients admitted to intensive care units using the 2013 Premier Hospital Database (Premier, Inc.). Observed and predicted hospital mortality were evaluated by observed and predicted day 1 fluid administration, using the difference in predicted and observed outcomes to adjust for disease severity between groups. Both predictive models were validated using a second large administrative database (Truven Health Analytics Inc.). Secondary outcomes included duration of mechanical ventilation, hospital and ICU length of stay, and cost. RESULTS:Among 33,831 patients, observed hospital mortality was incrementally higher than predicted for each additional liter of day 1 fluid beginning at 7 L (40.9% vs. 37.2%, p?=?0.008). Compared to patients that received expected (±?1.5?L predicted) day 1 fluid volumes, greater-than-expected fluid resuscitation was associated with increased risk-adjusted hospital mortality (52.3% vs. 45.0%, p?<?0.0001) among all patients with shock and among a subgroup of shock patients with comorbid conditions predictive of lower fluid volume administration (47.1% vs. 41.5%, p?<?0.0001). However, in patients with shock but without such conditions, both greater-than-expected (57.5% vs. 49.2%, p <?0.0001) and less-than-expected (52.1% vs. 49.2%, p?=?0.037) day 1 fluid resuscitation were associated with increased risk-adjusted hospital mortality. CONCLUSIONS:Highly variable day 1 fluid resuscitation was associated with a non-uniform impact on risk-adjusted hospital mortality among distinct subgroups of mechanically ventilated patients with shock. These findings support closer evaluation of fluid resuscitation strategies that include broadly applied fluid volume targets in the early phase of shock resuscitation.

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Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

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Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

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