Hospital Use and Mortality among Medicare Beneficiaries in Boston and New Haven

Wennberg, John E.; Freeman, Jean L.; Shelton, Roxanne M.; Bubolz, Thomas A.

doi:10.1056/nejm198910263211706

Cited by 291 publications

(125 citation statements)

References 8 publications

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“…This study adds to the questions previously raised about the use of in-hospital mortality rates as a quality indicator for hospitals, 29 even when risk adjustment is used. Current methods to monitor quality may be fl awed if they do not adequately control for selection bias caused by unmeasured confounders.…”

Section: Discussionmentioning

confidence: 97%

Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care

James¹,

Li²,

Ward³

2007

The Annals of Family Medicine

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PURPOSE Patients with acute myocardial infarction have higher mortality rates in rural hospitals than in urban hospitals, suggesting substandard quality of care in the rural setting. We examined characteristics of patients experiencing myocardial infarction and used an instrumental variable technique to adjust for unmeasured confounding when comparing mortality rates for these hospitals. RESULTS Unadjusted and risk-adjusted mortality rates using logistic regression models indicated signifi cantly lower in-hospital mortality for patients with myocardial infarction admitted to urban hospitals than for their counterparts admitted to rural hospitals (unadjusted values, 6.4% vs 14%). The urban and rural groups differed signifi cantly on characteristics studied, however. Analyses indicated that the traditional logistic regression models were possibly confounded by unmeasured patient factors, and when the same data were analyzed with the instrumental variable technique, mortality differences disappeared. METHODSCONCLUSIONS In Iowa, mortality from myocardial infarction in rural hospitals is not higher than that in urban ones after controlling for unmeasured confounders. Current risk-adjustment models may not be suffi cient when assessing hospitals that perform different functions within the health care system. Unmeasured confounding is a major concern when comparing heterogeneous and undifferentiated populations.

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Section: Discussionmentioning

confidence: 97%

Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care

James¹,

Li²,

Ward³

2007

The Annals of Family Medicine

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“…These differences most likely reflect variability in hospitalization practices by region, which has been shown before. 26 Differences in mortality among hospitalized patients in Boston, Mass, and New Haven, Conn, have been ascribed to differences in hospital admission practices in the 2 cities rather than to any discrepancy in hospital care or overall mortality. 26 In addition, variation in blood culture collection practices by area may have contributed to the regional differences in case-fatality rates.…”

Section: Discussionmentioning

confidence: 99%

Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995-1997

Feikin

Schuchat²,

Kolczak³

et al. 2000

Am J Public Health

514

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OBJECTIVES: This study examined epidemiologic factors affecting mortality from pneumococcal pneumonia in 1995 through 1997. METHODS: Persons residing in a surveillance area who had community-acquired pneumonia requiring hospitalization and Streptococcus pneumoniae isolated from a sterile site were included in the analysis. Factors affecting mortality were evaluated in univariate and multivariate analyses. The number of deaths from pneumococcal pneumonia requiring hospitalization in the United States in 1996 was estimated. RESULTS: Of 5837 cases, 12% were fatal. Increased mortality was associated with older age, underlying disease. Asian race, and residence in Toronto/Peel, Ontario. When these factors were controlled for, increased mortality was not associated with resistance to penicillin or cefotaxime. However, when deaths during the first 4 hospital days were excluded, mortality was significantly associated with penicillin minimum inhibitory concentrations of 4.0 or higher and cefotaxime minimum inhibitory concentrations of 2.0 or higher. In 1996, about 7000 to 12,500 deaths occurred in the United States from pneumococcal pneumonia requiring hospitalization. CONCLUSIONS: Older age and underlying disease remain the most important factors influencing death from pneumococcal pneumonia. Mortality was not elevated in most infections with beta-lactam-resistant pneumococci.

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“…Regional variation in treatment patterns has been documented for many diseases in adults and children. [19][20][21][22] However, the factors underlying these broad The ecologic approach that we and others6r7 have used in assessing determinants of type of surgery for localized breast cancer has not explained a strong pattern of regional variation. The next step should be research directed at decision making by individual patients and their physicians.…”

Section: Discussionmentioning

confidence: 99%

Determinants of receiving breast-conserving surgery. The surveillance, epidemiology, and end results program, 1983–1986

Samet

Hunt

Farrow

1994

Cancer

100

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Background. Although breast‐conserving surgery was used with increasing frequency during the 1980s for management of breast cancer, most women still undergo mastectomy, and a substantial variation has been documented in the proportion of women receiving breast‐conserving surgery across regions of the country. Using data from the Surveillance, Epidemiology, and End Results (SEER) Program for 1983–1986, we assessed characteristics of the county of residence as predictors of receipt of breast‐conserving surgery and determined whether regional variation persisted after considering these characteristics. Methods. The data used involved all 19,661 non‐Hispanic white women with localized breast cancer diagnosed in 1983 through 1986 in the nine SEER regions. Information on county characteristics was obtained from standard sources and merged with the SEER data. Univariate and multivariate statistical methods were used to assess the effects of county characteristics on type of surgery for breast cancer. Results. As anticipated, age was a strong predictor of type of surgery. In analyses that controlled for age, county characteristics that significantly predicted receipt of breast‐conserving surgery included physician‐to‐population ratio, education and income levels, the presence of a cancer center, and the presence of a city of at least 100,000. After controlling for these factors using multiple logistic regression, substantial regional variation persisted. Conclusions. Regional variation in treatment of localized breast cancer across the SEER regions is not explained by patient's age or county characteristics. Research is needed to address the decision making of individual patients and their physicians regarding type of surgery.

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Hospital Use and Mortality among Medicare Beneficiaries in Boston and New Haven

Cited by 291 publications

References 8 publications

Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care

Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care

Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995-1997

Determinants of receiving breast-conserving surgery. The surveillance, epidemiology, and end results program, 1983–1986

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