Variation in Hospital Admissions Among Small Areas: A Comparison of Maine and Michigan

McMahon, Laurence F.; Wolfe, Robert A.; Tedeschi, Philip

doi:10.1097/00005650-198906000-00005

Cited by 108 publications

(37 citation statements)

References 6 publications

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“…[6][7][8][9] One way for providers to reduce variation in hospitalization would be to use proven decision-making tools.…”

Section: Introductionmentioning

confidence: 99%

“…5 Several studies show that there is unexplained variability among ED physicians' decisions to admit or discharge patients. [6][7][8][9] One way for providers to reduce variation in hospitalization would be to use proven decision-making tools. 10 To date, pneumonia severity tools have been developed and validated in cohorts of hospitalized patients with very little information in outpatient cohorts.…”

mentioning

confidence: 99%

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CURB‐65 Performance Among Admitted and Discharged Emergency Department Patients With Community‐acquired Pneumonia

Sharp

Jones²,

et al. 2016

Academic Emergency Medicine

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Objectives: Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP).Methods: A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality.Results: The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0).Conclusions: CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care.ACADEMIC EMERGENCY MEDICINE 2016;23:400-405 © 2016 by the Society for Academic Emergency Medicine P neumonia is a leading cause of death in the United States and accounts for over 1.2 million hospitalizations annually, resulting in $10.2 billion in health care costs.1,2 Unnecessary hospitalizations put patients at risk for adverse events and strain the limited resources of an already taxed health care system. 3,4 As the key decision makers about hospitalization, emergency department (ED) providers play a key role in assuring appropriate use of the hospital.5 Several studies show that there is unexplained variability among ED physicians' decisions to admit or discharge patients. [6][7][8][9] One way for providers to reduce variation in hospitalization would be to use proven decision-making tools. 10To date, pneumonia severity tools have been developed and validated in cohorts of hospitalized patients with very little information in outpatient cohorts.11-13 To

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“…[6][7][8][9] One way for providers to reduce variation in hospitalization would be to use proven decision-making tools.…”

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

CURB‐65 Performance Among Admitted and Discharged Emergency Department Patients With Community‐acquired Pneumonia

Sharp

Jones²,

et al. 2016

Academic Emergency Medicine

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“…There are also unexplained geographic and local differences in the resource utilization outcomes of hospital admission rates and length of hospital stay. [9][10][11] A growing number of processes of pneumonia care have been associated with risk-adjusted mortality rates, and have been proposed as valid indicators of the quality of inpatient care. These include the following: antibiotic selection, 12,13 time to first dose of antibiotics, 5 performance of blood cultures, 5 assessment of oxygenation, 5 and discharge prior to clinical stability.…”

mentioning

confidence: 99%

Limited Impact of a Multicenter Intervention To Improve the Quality and Efficiency of Pneumonia Care

Halm

Horowitz

Silver

et al. 2004

Chest

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Study objectives-To evaluate the impact of a multifactorial intervention to improve the quality, efficiency, and patient understanding of care for community-acquired pneumonia.Design-Times series cohort study. Setting-Four academic health centers in the New York City metropolitan area.Patients or participants-All consecutive adults hospitalized for pneumonia during a 5-month period before (n = 1,013) and after (n = 1,081) implementation of an inpatient quality improvement (QI) initiative.Interventions-A multidisciplinary team of opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted educational sessions with physicians, distributed pocket reminder cards, promoted standardized orders, and developed bilingual patient education materials.Measurements and results-The average age was 71.4 years, and 44.1% of cases were low risk, 36.8% were moderate risk, and 19.2% were high risk. The preintervention and postintervention groups were well matched on age, sex, race, nursing home residence, pneumonia severity, initial presentation, and most major comorbidities. The intervention increased the use of guideline-recommended antimicrobial therapy from 78.1 to 83.4% (p = 0.003). There was also a borderline decrease in the proportion of patients being discharged prior to becoming clinically stable, from 27.0 to 23.5% (p = 0.06). However, there were no improvements in the other targeted indicators, including time to first dose of antibiotics, proportion receiving antibiotics within 8 h, timely switch to oral antibiotics, timely discharge, length of stay, or patient education outcomes.Correspondence to: Ethan A. Halm, MD, MPH, Division of General Internal Medicine, Box 1087, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029; ethan.halm@mountsinai.org. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (permissions@chestnet.org). NIH Public Access Author ManuscriptChest. Author manuscript; available in PMC 2015 January 21. Published in final edited form as:Chest. 2004 July ; 126(1): 100-107. doi:10.1378/chest.126.1.100. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptConclusions-This real-world QI program was able to improve modestly on some quality indicators, but not effect resource use or patient knowledge of their disease. Changing physician and organizational behavior in academic health centers will require the development and implementation of more intensive, system-oriented strategies.Keywords antibiotic therapy; guidelines; outcomes; pneumonia; quality improvementNearly one million patients are hospitalized with community-acquired pneumonia each year in the United States, at an annual cost of $9 billion. 1,2 It is the most common infectious cause of death, the sixth-leading cause of death overall, and has an average mortality rate of 14%. 3,4 Previous work 5-8 has demonstrated substantial variations in the quality of inpatient pneumonia care between hospitals ...

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“…Sin embargo, estos índices fueron diseñados y validados para predecir el riesgo de muerte de los enfermos 18,19.23 , por lo que se desconoce si entregan además información clínicamente relevante sobre su evolución en el hospital. Evaluar la gravedad y decidir el lugar de manejo del enfermo (ambulatorio, sala o UCI) es una decisión clínica compleja, la cual puede verse dificultada porque los médicos clínicos suelen subestimar, y a veces sobreestimar, la gravedad de la enfermedad [15][16][17] . Por este motivo, se han diseñado los índices pronósticos para ayudar a los médicos clínicos a evaluar la gravedad de los pacientes con neumonía 6,14,[24][25][26] .…”

Section: Discussionunclassified

“…Los clínicos tienden a sobreestimar o subestimar la gravedad de los pacientes con neumonía atendidos en los Servicios de Atención Primaria (consultorios y servicios de urgencia) [15][16][17] . La evaluación de la gravedad basada en elementos clínicos objetivos permite reducir la tasa de hospitalización de pacientes de bajo riesgo, disminuyendo los costos sanitarios y el riesgo de eventos adversos asociados a la estadía en el hospital, e identificar a los pacientes de alto riesgo que deben ser manejados en el hospital debido al riesgo de complicaciones y muerte, optimizando el uso de los recursos sanitarios 14 .…”

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Evaluación de los índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad

et al. 2017

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Variation in Hospital Admissions Among Small Areas: A Comparison of Maine and Michigan

Cited by 108 publications

References 6 publications

CURB‐65 Performance Among Admitted and Discharged Emergency Department Patients With Community‐acquired Pneumonia

CURB‐65 Performance Among Admitted and Discharged Emergency Department Patients With Community‐acquired Pneumonia

Limited Impact of a Multicenter Intervention To Improve the Quality and Efficiency of Pneumonia Care

Evaluación de los índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad

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