Object. The objective of this study was to identify specific independent risk factors for surgical site infections (SSIs) occurring after laminectomy or spinal fusion. Methods. The authors performed a retrospective case-control study of data obtained in patients between 1996 and 1999 who had undergone laminectomy and/or spinal fusion. Forty-one patients with SSI or meningitis were identified, and data were compared with those acquired in 178 uninfected control patients. Risk factors for SSI were determined using univariate analyses and multivariate logistic regression. The spinal surgery—related SSI rate (incisional and organ space) during the 4-year study period was 2.8%. Independent risk factors for SSI identified by multivariate analysis were postoperative incontinence (odds ratio [OR] 8.2, 95% confidence interval [CI] 2.9–22.8), posterior approach (OR 8.2, 95% CI 2–33.5), procedure for tumor resection (OR 6.2, 95% CI 1.7–22.3), and morbid obesity (OR 5.2, 95% CI 1.9–14.2). In patients with SSI the postoperative hospital length of stay was significantly longer than that in uninfected patients (median 6 and 3 days, respectively; p < 0.001) and were readmitted to the hospital for a median additional 6 days for treatment of their infection. Repeated surgery due to the infection was required in the majority (73%) of infected patients. Conclusions. Postoperative incontinence, posterior approach, surgery for tumor resection, and morbid obesity were independent risk factors predictive of SSI following spinal surgery. Interventions to reduce the risk for these potentially devastating infections need to be developed.

Recent federal policies and actions support the adoption of health information exchange (HIE) in order to improve healthcare by addressing fragmented personal health information. However, concerted efforts at facilitating HIE have existed for over two decades in this country. The lessons of these experiences include a recurrence of barriers and challenges beyond those associated with technology. Without new strategies, the current support and methods of facilitating HIE may not address these barriers.

BackgroundU.S. healthcare organizations are confronted with numerous and varied transformational strategies promising improvements along all dimensions of quality and performance. This article examines the peer-reviewed literature from the U.S. for evidence of effectiveness among three current popular transformational strategies: Six Sigma, Lean/Toyota Production System, and Studer's Hardwiring Excellence.MethodsThe English language health, healthcare management, and organizational science literature (up to December 2007) indexed in Medline, Web of Science, ABI/Inform, Cochrane Library, CINAHL, and ERIC was reviewed for studies on the aforementioned transformation strategies in healthcare settings. Articles were included if they: appeared in a peer-reviewed journal; described a specific intervention; were not classified as a pilot study; provided quantitative data; and were not review articles. Nine references on Six Sigma, nine on Lean/Toyota Production System, and one on StuderGroup meet the study's eligibility criteria.ResultsThe reviewed studies universally concluded the implementations of these transformation strategies were successful in improving a variety of healthcare related processes and outcomes. Additionally, the existing literature reflects a wide application of these transformation strategies in terms of both settings and problems. However, despite these positive features, the vast majority had methodological limitations that might undermine the validity of the results. Common features included: weak study designs, inappropriate analyses, and failures to rule out alternative hypotheses. Furthermore, frequently absent was any attention to changes in organizational culture or substantial evidence of lasting effects from these efforts.ConclusionDespite the current popularity of these strategies, few studies meet the inclusion criteria for this review. Furthermore, each could have been improved substantially in order to ensure the validity of the conclusions, demonstrate sustainability, investigate changes in organizational culture, or even how one strategy interfaced with other concurrent and subsequent transformation efforts. While informative results can be gleaned from less rigorous studies, improved design and analysis can more effectively guide healthcare leaders who are motivated to transform their organizations and convince others of the need to employ such strategies. Demanding more exacting evaluation of projects consultants, or partnerships with health management researchers in academic settings, can support such efforts.

BackgroundHospital readmissions are a leading topic of healthcare policy and practice reform because they are common, costly, and potentially avoidable events. Hospitals face the prospect of reduced or eliminated reimbursement for an increasing number of preventable readmissions under nationwide cost savings and quality improvement efforts. To meet the current changes and future expectations, organizations are looking for potential strategies to reduce readmissions. We undertook a systematic review of the literature to determine what factors are associated with preventable readmissions.MethodsWe conducted a review of the English language medicine, health, and health services research literature (2000 to 2009) for research studies dealing with unplanned, avoidable, preventable, or early readmissions. Each of these modifying terms was included in keyword searches of readmissions or rehospitalizations in Medline, ISI, CINAHL, The Cochrane Library, ProQuest Health Management, and PAIS International. Results were limited to US adult populations.ResultsThe review included 37 studies with significant variation in index conditions, readmitting conditions, timeframe, and terminology. Studies of cardiovascular-related readmissions were most common, followed by all cause readmissions, other surgical procedures, and other specific-conditions. Patient-level indicators of general ill health or complexity were the commonly identified risk factors. While more than one study demonstrated preventable readmissions vary by hospital, identification of many specific organizational level characteristics was lacking.ConclusionsThe current literature on preventable readmissions in the US contains evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions. However, definitional variations, clear gaps, and methodological challenges limit translation of this literature into guidance for the operation and management of healthcare organizations. We recommend that those organizations that propose to reward reductions in preventable readmissions invest in additional research across multiple hospitals in order to fill this serious gap in knowledge of great potential value to payers, providers, and patients.

Ethnic minority and low-income populations have the highest rates of cardiovascular disease and the lowest rates of leisure-time physical activity. Because physical activity reduces the risk of premature death and disability from cardiovascular disease, researching correlates to such activity in these populations is an important aspect of health promotion in the US. To identify environmental, policy, and cultural barriers to physical activity in women, The Women's Cardiovascular Health Network Project conducted focus groups with White, African American, Latina, and American Indian women aged 20-50 years. The focus groups were audiotaped, transcribed, and analyzed with QSR NUD*IST qualitative software using a set of codes developed a priori by the research team. Family priorities were a main barrier to physical activity in all the groups. Having multiple roles as wife, mother, daughter, and as an active community member was mentioned as time-consuming and difficult, leaving little time or energy for exercise. Cultural barriers, which varied among the groups, included acculturation issues, lack of community support, and lack of past experience with exercise. Physical activity interventions suggested involved work programs, family-friendly programs, increased social support, and the availability of safer places to exercise such as parks, well-lit walking trails, and recreation centers. Many of the barriers were common to all groups (e.g., family priority) while some were unique (e.g., lack of community support). Assessing and addressing the issues raised should be considered when planning physical activity interventions for these populations.Physical activity is an important part of health promotion and disease prevention (USDHHS, 1996). Reducing disparities in health and increasing physical activity levels in all populations is paramount to the future health of our nation. For physical activity interventions to be effective, however, they must adequately address barriers to activity and promote factors that enable it. As indicated by our projects in this series, these barriers and enablers are both common and unique across race/ethnicity. Common barriers, such as lack of time, have been cited in

This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.

The current systematic review found that studies with more rigorous designs all reported benefits from HIE. Such benefits include fewer duplicated procedures, reduced imaging, lower costs, and improved patient safety. We also found that studies evaluating community HIEs were more likely to find benefits than studies that evaluated enterprise HIEs or vendor-mediated exchanges. Overall, these finding bode well for the HIEs ability to deliver on anticipated improvements in care delivery and reduction in costs.

Health information exchange (HIE), which is the transfer of electronic information such as laboratory results, clinical summaries, and medication lists, is believed to boost efficiency, reduce health care costs, and improve outcomes for patients. Stimulated by federal financial incentives, about two-thirds of hospitals and almost half of physician practices are now engaged in some type of HIE with outside organizations. To determine how HIE has affected such health care measures as cost, service use, and quality, we identified twenty-seven scientific studies, extracted selected characteristics from each, and meta-analyzed these characteristics for trends. Overall, 57 percent of published analyses reported some benefit from HIE. However, articles employing study designs having strong internal validity, such as randomized controlled trials or quasi-experiments, were significantly less likely than others to associate HIE with benefits. Among six articles with strong internal validity, one study reported paradoxical negative effects, three studies found no effect, and two studies reported that HIE led to benefits. Furthermore, these two studies had narrower focuses than the others. Overall, little generalizable evidence currently exists regarding benefits attributable to HIE.