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Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning.

ABSTRACT: PURPOSE:We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation. METHODS:We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess national variation in 90-day in-hospital mortality rates in LTACHs from 2013. RESULTS:The administrative risk-adjustment model was derived using data from 9447 patients admitted to 221 LTACHs in 2003. The model had good discrimination (C statistic=0.72) and calibration. Compared to a clinically derived model using data from 1163 patients admitted to 14 LTACHs, the administrative model generated similar performance estimates. National variation in risk-adjusted mortality was assessed using data from 20,453 patients admitted to 380 LTACHs in 2013. LTACH-specific risk-adjusted mortality rates varied from 8.4% to 48.1% (median: 24.2%, interquartile range: 19.7%-30.7%). CONCLUSIONS:LTACHs vary widely in mortality rates, underscoring the need to better understand the sources of this variation and improve the quality of care for patients requiring long-term ventilator weaning.

SUBMITTER: Kahn JM

PROVIDER: S-EPMC6014911 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning.

Kahn Jeremy M JM Davis Billie S BS Le Tri Q TQ Yabes Jonathan G JG Chang Chung-Chou H CH Angus Derek C DC

Journal of critical care 20180323

<h4>Purpose</h4>We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation.<h4>Methods</h4>We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess nationa ...[more]

PMID: 29627660

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Project description:ObjectivesThere is limited evidence on the impact of protocolized ventilator weaning in pediatric acute respiratory distress syndrome, despite utilization in clinical trials and clinical care. We aimed to determine whether protocolized ventilator weaning shortens mechanical ventilation duration and PICU length of stay in pediatric acute respiratory distress syndrome survivors.DesignSecondary analysis of a prospective pediatric acute respiratory distress syndrome (Berlin definition) cohort from July 2011 to June 2019 analyzed using interrupted time series analysis pre- and postimplementations of a ventilator-weaning pathway. We compared duration of invasive ventilation and PICU length of stay in survivors before and after implementation of a ventilator-weaning pathway. We excluded PICU nonsurvivors and subjects with greater than 100 ventilator days.SettingLarge academic tertiary-care PICU.PatientsChildren with acute respiratory distress syndrome who survived to PICU discharge with less than or equal to 100 days of invasive mechanical ventilation.InterventionsImplementation of a ventilator-weaning pathway on May 2016.Measurements and main resultsOf 723 children with acute respiratory distress syndrome, 132 subjects died and six subjects with ventilation greater than 100 days were excluded. Of the remaining 585 subjects, 375 subjects had acute respiratory distress syndrome prior to pathway intervention and 210 after. Patients in the preintervention epoch were younger, more likely to have infectious acute respiratory distress syndrome, and had increased use of alternative ventilator modes. Pathway adoption was rapid and sustained. Controlling for temporality, pathway implementation was associated with a decrease of a median 3.6 ventilator days (95% CI, -5.4 to -1.7; p < 0.001). There was no change in the reintubation rates. Results were robust to multiple sensitivity analyses adjusting for confounders.ConclusionsVentilator-weaning pathway implementation shortened invasive ventilation duration in pediatric acute respiratory distress syndrome survivors with no change in reintubation. The effect size of this intervention was comparable with those targeted in acute respiratory distress syndrome trials.

Project description:ImportanceLittle contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.ObjectiveTo assess and compare mortality and readmission rates among men in VA and non-VA hospitals.Design, setting, and participantsCross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA).ExposuresHospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital.Main outcomes and measuresFor each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed.ResultsWe studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, -0.22; 95% CI, -0.40 to -0.04) and HF (-0.63; 95% CI, -0.95 to -0.31), and mortality rates for pneumonia were not significantly different (-0.03; 95% CI, -0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91).Conclusions and relevanceAmong older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small.

Project description:BackgroundLittle is known about cross-hospital differences in critical care units admission rates and related resource utilization and outcomes among patients hospitalized with acute coronary syndromes (ACS) or heart failure (HF).Methods and resultsUsing a population-based sample of 16,078 patients admitted to a critical care unit with a primary diagnosis of ACS (n=14,610) or HF (n=1467) between April 1, 2003 and March 31, 2013 in Alberta, Canada, we stratified hospitals into high (>250), medium (200 to 250), or low (<200) volume based on their annual volume of all ACS and HF hospitalization. The percentage of hospitalized patients admitted to critical care units varied across low, medium, and high-volume hospitals for both ACS and HF as follows: 77.9%, 81.3%, and 76.3% (P<0.001), and 18.0%, 16.3%, and 13.0% (P<0.001), respectively. Compared to low-volume units, critical care patients with ACS and HF admitted to high-volume hospitals had shorter mean critical care stays (56.6 versus 95.6 hours, P<0.001), more critical care procedures (1.9 versus 1.2 per patient, <0.001), and higher resource-intensive weighting (2.8 versus 1.5, P<0.001). No differences in in-hospital mortality (5.5% versus 6.2%, adjusted odds ratio 0.93; 95% CI, 0.61 to 1.41) were observed between high- and low-volume hospitals; however, 30-day cardiovascular readmissions (4.6% versus 6.8%, odds ratio 0.77; 95% CI, 0.60 to 0.99) and cardiovascular emergency-room visits (6.6% versus 9.5%, odds ratio 0.80; 95% CI, 0.69 to 0.94) were lower in high-volume compared to low-volume hospitals. Outcomes stratified by ACS or HF admission diagnosis were similar.ConclusionsCardiac patients hospitalized in low-volume hospitals were more frequently admitted to critical care units and had longer hospitals stays despite lower resource-intensive weighting. These findings may provide opportunities to standardize critical care utilization for ACS and HF patients across high- and low-volume hospitals.

Project description:AimsAcute heart failure (AHF) leads to a drastic increase in mortality and rehospitalization. The aim of the study was to identify prognostic variables in a real-life population of AHF patients admitted to the emergency department with acute shortness of breath.Methods and resultsWe evaluated potential predictors of mortality in 728 consecutive patients admitted to the emergency department with AHF. Possible predictors of all-cause and cardiovascular (CV) mortality were investigated by Cox and Fine and Gray models at multivariable analysis. Among the 728 patients, 256 died during the entire follow-up, 142 of these due to CV cause. The 1 year mortality rate was 20%, with the highest risk of death during the index hospitalization (with 8% estimate in-hospital mortality at 30 days). A higher risk of events during the index hospitalization was more evident for the CV deaths, for which we found a cumulative 1 year incidence of 12% with a cumulative incidence in the first 30 days of hospitalization of about 5%. At multivariable analysis, age (P < 0.001), New York Heart Association (NYHA) class IV vs. I-II-III (P = 0.001), systolic blood pressure (P < 0.001), non-cardiac co-morbidities (≥3 vs. 0, P = 0.05), oxygen saturation (P = 0.03), serum creatinine (P < 0.001), and left ventricular ejection fraction (LVEF) (40-49% vs. <40%, P = 0.004; ≥50% vs. <40%, P = 0.003) were independent predictors of all-cause mortality during the entire follow-up. Age (P = 0.03), systolic blood pressure (P = 0.01), oxygen saturation (P = 0.03), serum creatinine (P = 0.02), and LVEF (40-49% vs. <40%, P = 0.03; ≥50% vs. <40%, P = 0.004) were independent predictors of CV mortality during the entire follow-up. NYHA class IV vs. I-II-III (P < 0.001), serum creatinine (P = 0.01), and LVEF (40-49% vs. <40%, P = 0.02; ≥50% vs. <40%, P < 0.001) remained independent predictors for in-hospital death, while only serum creatinine (P = 0.04), LVEF (40-49% vs. <40%: 0.32, P = 0.04; ≥50% vs. <40%, P < 0.001), and NYHA class vs. I-II-III (P = 0.02) remained predictors for in-hospital CV mortality.ConclusionsIn this real-life cohort of patients with AHF, the results showed a similar mortality rate comparing with other analysis and with the most important registries. Age, NYHA class IV, systolic blood pressure, creatinine levels, sodium levels, and ejection fraction were independent predictors of 1 year mortality, while LVEF <40% was the only predictor of both all-cause mortality and CV mortality.

Project description:Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation.To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.Qualitative study that used site visits and in-depth interviews.Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics.158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method.Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals.The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed.High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI.Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

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Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning.

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Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning.

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