Background: Care from high-volume centers or surgeons has been associated with lower mortality rates in coronary artery bypass surgery, but how volume and quality of care relate to each other is not well understood. Objective: To determine how volume and differences in quality of care influence outcomes after coronary artery bypass surgery. Design: Observational cohort. Setting: 164 hospitals in the United States. Patients: 81 289 patients 18 years or older who had coronary artery bypass grafting from 1 October 2003 to 1 September 2005. Measurements: Hospital and surgeon case volumes were estimated by using a data set. Quality measures were defined by whether patients received specific medications and by counting the number of measures missed. Hierarchical models were used to estimate effects of volume and quality on death and readmission up to 30 days. Results: After adjustment for clinical factors, lowest surgeon volume and highest hospital volume were associated with higher mortality rates and lower readmission risk, respectively. Patients who did not receive aspirin (odds ratio, 1.89 [95% CI, 1.65 to 2.16) or β-blockers (odds ratio, 1.29 [CI, 1.12 to 1.49]) had higher odds for death, after adjustment for clinical risk factors and case volume. Adjustment for individual quality measures did not alter associations between volume and readmission or death. However, if no quality measures were missed, mortality rates at the lowest-volume centers (adjusted mortality rate, 1.05% [CI, 0.81% to 1.29%]) and highest-volume centers (adjusted mortality rate, 0.98% [CI, 0.72% to 1.25%]) were similar. Limitation: Because administrative data were used, the quality measures may not replicate measures collected through chart abstraction. Conclusion: Maximizing adherence to quality measures is associated with improved mortality rates, independent of hospital or surgeon volume. Primary Funding Source: California HealthCare Foundation.
Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame.
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The aim of this study is to determine if selective transcatheter arterial embolization (TAE) of the branches of the internal iliac artery in patients with pelvic trauma is a risk for gluteal necrosis.Retrospective chart review.Civilian Level I trauma center.Twenty patients with pelvic fractures and hemorrhage.Selective and nonselective TAE of the internal iliac artery and its branches.The location of all fractures was identified as well as the fracture type. Selective TAE was also distinguished from nonselective TAE. Orthopaedic surgical intervention was recorded. Cases of gluteal necrosis and wound infection were recorded as well as renal failure and anaphylactic reaction to intravenous contrast.Of the 551 patients identified with pelvic fractures, 20 patients were identified to have undergone TAE from January 2004 to January 2009. Of these, 18 cases were treated with selective TAE and two with nonselective unilateral TAE. No complications of gluteal muscle or pelvic skin necrosis, wound infection, renal failure, or anaphylaxis were noted in any of these cases. Average patient age was 55 years with average Injury Severity Score 17. Eleven cases underwent orthopaedic surgical procedures, eight of which involved open reduction and internal fixation of the acetabulum or hemiarthroplasty of the hip.Selective TAE of internal iliac branches including the gluteal arterial branches appears to be safe in patients with pelvic and acetabular fractures with and without orthopaedic surgical treatment. Nonselective TAE of the internal iliac artery may also be safe when performed unilaterally.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
To compare different definitions of multimorbidity to identify patients with higher health care resource utilization.We used a multinational retrospective cohort including 147,806 medical inpatients discharged from 11 hospitals in 3 countries (United States, Switzerland, and Israel) between January 1, 2010, and December 31, 2011. We compared the area under the receiver operating characteristic curve (AUC) of 8 definitions of multimorbidity, based on International Classification of Diseases codes defining health conditions, the Deyo-Charlson Comorbidity Index, the Elixhauser-van Walraven Comorbidity Index, body systems, or Clinical Classification Software categories to predict 30-day hospital readmission and/or prolonged length of stay (longer than or equal to the country-specific upper quartile). We used a lower (yielding sensitivity ≥90%) and an upper (yielding specificity ≥60%) cutoff to create risk categories.Definitions had poor to fair discriminatory power in the derivation (AUC, 0.61-0.65) and validation cohorts (AUC, 0.64-0.71). The definitions with the highest AUC were number of (1) health conditions with involvement of 2 or more body systems, (2) body systems, (3) Clinical Classification Software categories, and (4) health conditions. At the upper cutoff, sensitivity and specificity were 65% to 79% and 50% to 53%, respectively, in the validation cohort; of the 147,806 patients, 5% to 12% (7474 to 18,008) were classified at low risk, 38% to 55% (54,484 to 81,540) at intermediate risk, and 32% to 50% (47,331 to 72,435) at high risk.Of the 8 definitions of multimorbidity, 4 had comparable discriminatory power to identify patients with higher health care resource utilization. Of these 4, the number of health conditions may represent the easiest definition to apply in clinical routine. The cutoff chosen, favoring sensitivity or specificity, should be determined depending on the aim of the definition.
