Objectives. To examine the criterion validity of the Agency for Health Care Research and Quality (AHRQ) Patient Safety Indicators (PSIs) using clinical data from the Veterans Health Administration (VA) National Surgical Quality Improvement Program (NSQIP). Data Sources. Fifty five thousand seven hundred and fifty two matched hospitalizations from 2001 VA inpatient surgical discharge data and NSQIP chart-abstracted data. Study Design. We examined the sensitivities, specificities, positive predictive values (PPVs), and positive likelihood ratios of five surgical PSIs that corresponded to NSQIP adverse events. We created and tested alternative definitions of each PSI. Data Collection. FY01 inpatient discharge data were merged with 2001 NSQIP data abstracted from medical records for major noncardiac surgeries. Principal Findings. Sensitivities were 19-56 percent for original PSI definitions; and 37-63 percent using alternative PSI definitions. PPVs were 22-74 percent and did not improve with modifications. Positive likelihood ratios were 65-524 using original definitions, and 64-744 using alternative definitions. ''Postoperative respiratory failure'' and ''postoperative wound dehiscence'' exhibited significant increases in sensitivity after modifications. Conclusions. PSI sensitivities and PPVs were moderate. For three of the five PSIs, AHRQ has incorporated our alternative, higher sensitivity definitions into current PSI algorithms. Further validation should be considered before most of the PSIs evaluated herein are used to publicly compare or reward hospital performance.

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Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.

Although lack of access to nonemergency medical transportation (NEMT) is a barrier to health care, national transportation and health care surveys have not comprehensively addressed that link. Nationally representative studies have not investigated the magnitude of the access problem or the characteristics of the population that experiences access problems. The current study, relying primarily on national health care studies, seeks to address both of those shortcomings. Results indicate that about 3.6 million Americans do not obtain medical care because of a lack of transportation in a given year. On average, they are disproportionately female, poorer, and older; have less education; and are more likely to be members of a minority group than those who obtain care. Although such adults are spread across urban and rural areas much like the general population, children lacking transportation are more concentrated in urban areas. In addition, these 3.6 million experience multiple conditions at a much higher rate than do their peers. Many conditions that they face, however, can be managed if appropriate care is made available. For some conditions, this care is cost-effective and results in health care cost savings that outweigh added transportation costs. Thus, it is found that great opportunity exists to achieve net societal benefits and to improve the quality of life of this population by increasing its access to NEMT. Furthermore, modifications to national health care and transportation data sets are recommended to allow more direct assessment of this problem.

Although almost 42% of unplanned readmissions were identified as clinically related, the majority of unplanned readmissions were unrelated to the index hospitalization. Quality improvement interventions targeted at processes of care associated with the index hospitalization are likely to be most effective in reducing clinically related readmissions. It is less clear how to reduce nonclinically related readmissions; these may involve broader factors than inpatient care.

Key Points Question How can coded and free-text data from electronic medical records be used to support infection tracking and other patient safety surveillance following common but understudied cardiac device procedures? Findings In this national cohort study of 19 212 patients who underwent cardiovascular implantable electronic device procedures in the US Department of Veterans Affairs health care system, an algorithm to reliably identify cases with a true 90-day infection by combining coded data (eg, diagnosis of a comorbid condition) and free-text data extracted from clinical notes (eg, documentation of an infection by a cardiologist) was developed and validated. Text note searching was a useful and straightforward adjunct to coded data for surveillance. Meaning The findings of this study suggest that the algorithm to detect patients who received cardiovascular implantable electronic device and developed an infection has the potential to significantly enhance surveillance in an underserved area.