Quality of care and interhospital collaboration: a study of patient transfers in Italy.

OBJECTIVES: We examine the dynamics of patient-sharing relations within an Italian regional community of 35 hospitals serving approximately 1,300,000 people. We test whether interorganizational relations provide individual patients access to higher quality providers of care. RESEARCH DESIGN AND METHODS: We reconstruct the complete temporal sequence of the 3461 consecutive interhospital patient-sharing events observed between each pair of hospitals in the community during 2005-2008. We distinguish between transfers occurring between and within different medical specialties. We estimate newly derived models for relational event sequences that allow us to control for the most common forms of network-like dependencies that are known to characterize collaborative relations between hospitals. We use 45-day risk-adjusted readmission rate as a proxy for hospital quality. RESULTS: After controls (eg, geographical distance, size, and the existence of prior collaborative relations), we find that patients flow from less to more capable hospitals. We show that this result holds for patient being shared both between as well as within medical specialties. Nonetheless there are strong and persistent other organizational and relational effects driving transfers. CONCLUSIONS: Decentralized patient-sharing decisions taken by the 35 hospitals give rise to a system of collaborative interorganizational arrangements that allow the patient to access hospitals delivering a higher quality of care. This result is relevant for health care policy because it suggests that collaborative relations between hospitals may produce desirable outcomes both for individual patients, and for regional health care systems

Long-Term Quality of Life Among Survivors of Severe Sepsis: Analyses of Two International Trials.

OBJECTIVES: To describe the quality of life among sepsis survivors. DESIGN: Secondary analyses of two international, randomized clinical trials (A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis [derivation cohort] and PROWESS-SHOCK [validation cohort]). SETTING: ICUs in North and South America, Europe, Africa, Asia, and Australia. PATIENTS: Adults with severe sepsis. We analyzed only patients who were functional and living at home without help before sepsis hospitalization (n = 1,143 and 987 from A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, respectively). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, the average age of patients living at home independently was 63 and 61 years; 400 (34.9%) and 298 (30.2%) died by 6 months. In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis, 580 patients had a quality of life measured using EQ-5D at 6 months. Of these, 41.6% could not live independently (22.7% were home but required help, 5.1% were in nursing home or rehabilitation facilities, and 5.3% were in acute care hospitals). Poor quality of life at 6 months, as evidenced by problems in mobility, usual activities, and self-care domains were reported in 37.4%, 43.7%, and 20.5%, respectively, and the high incidence of poor quality of life was also seen in patients in PROWESS-SHOCK. Over 45% of patients with mobility and self-care problems at 6 months in A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis died or reported persistent problems at 1 year. CONCLUSIONS: Among individuals enrolled in a clinical trial who lived independently prior to severe sepsis, one third had died and of those who survived, a further one third had not returned to independent living by 6 months. Both mortality and quality of life should be considered when designing new interventions and considering endpoints for sepsis trials

Individualizing endpoints in randomized clinical trials to better inform individual patient care: the TARGET proposal

In practice, critical care practitioners individualize treatments and goals of care for each patient in light of that patient’s acute and chronic pathophysiology, as well as their beliefs and values. Yet critical care researchers routinely measure one endpoint for all patients during randomized clinical trials (RCTs), eschewing any such individualization. More recent methodology work has explored the possibility that enrollment criteria in RCTs can be individualized, as can data analysis plans. Here we propose that the specific endpoints of a RCT can be individualized—that is, different patients within a single RCT might have different secondary endpoints measured. If done rigorously and objectively, based on pre-randomization data, such individualization of endpoints may improve the bedside usefulness of information obtained during a RCT, while perhaps also improving the power and efficiency of any RCT. We discuss the theoretical underpinnings of this proposal in light of related innovations in RCT design such as sliding dichotomies. We discuss what a full elaboration of such individualization would require, and outline a pragmatic initial step towards the use of “individualized secondary endpoints” in a large RCT evaluating optimal enteral nutrition targets in the critically ill.Theodore J. Iwashyna and Adam M. Dean

Using existing data to address important clinical questions in critical care

Objective: With important technological advances in healthcare delivery and the internet, clinicians and scientists now have access to overwhelming number of available databases capturing patients with critical illness. Yet investigators seeking to answer important clinical or research questions with existing data have few resources that adequately describe the available sources and the strengths and limitations of each. This article reviews an approach to selecting a database to address health services and outcomes research questions in critical care, examines several databases that are commonly used for this purpose, and briefly describes some strengths and limitations of each. Data Sources: Narrative review of the medical literature. Summary: The available databases that collect information on critically ill patients are numerous and vary in the types of questions they can optimally answer. Selection of a data source must not only consider accessibility, but also the quality of the data contained within the database, and the extent to which it captures the necessary variables for the research question. Questions seeking causal associations (e.g. effect of treatment on mortality) usually either require secondary data that contain detailed information about demographics, laboratories, and physiology to best address non-random selection or sophisticated study design. Purely descriptive questions (e.g. incidence of respiratory failure) can often be addressed using secondary data with less detail such as administrative claims. Though each database has its own inherent limitations, all secondary analyses will be subject to the same challenges of appropriate study design and good observational research. Conclusion: The literature demonstrates that secondary analyses can have significant impact on critical care practice. While selection of the optimal database for a particular question is a necessary part of high-quality analyses, it is not sufficient to guarantee an unbiased study. Thoughtful and well-constructed study design and analysis approaches remain equally important pillars of robust science. Only through responsible use of existing data will investigators ensure that their study has the greatest impact on critical care practice and outcomes.AHRQ K08 HS020672, NIH K08 HL091249Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106051/1/Cooke - Existing data in critical care.pd

Presepsis Depressive Symptoms Are Associated with Incident Cognitive Impairment in Survivors of Severe Sepsis: A Prospective Cohort Study of Older Americans

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95538/1/jgs12001.pd

Child Injury Risks are Close to Home: Parent Psychosocial Factors Associated with Child Safety

Objective: In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors. Methods: We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data. Results: Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home. Conclusion: In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention

Critical care use during the course of serious illness.

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/2/04.AJRCCM.supp.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/1/04.AJRCCM.pd

Towards of a real-time Big Data architecture to intensive care

These days the exponential increase in the volume and variety of data stored by companies and organizations of various sectors of activity, has required to organizations the search for new solutions to improve their services and/or products, taking advantage of technological evolution. As a response to the inability of organizations to process large quantities and varieties of data, in the technological market, arise the Big Data. This emerging concept defined mainly by the volume, velocity and variety has evolved greatly in part by its ability to generate value for organizations in decision making. Currently, the health care sector is one of the five sectors of activity where the potential of Big Data growth most stands out. However, the way to go is still long and in fact there are few organizations, related to health care, that are taking advantage of the true potential of Big Data. The main target of this research is to produce a real-time Big Data architecture to the INTCare system, of the Centro Hospitalar do Porto, using the main open source big data solution, the Apache Hadoop. As a result of the first phase of this research we obtained a generic architecture who can be adopted by other Intensive Care Units."This work has been supported by COMPETE: POCI-01-0145-FEDER-007043 and FCT - Fundacao para a Ciencia e Tecnologia within the Project Scope: UID/CEC/00319/2013." This work is also supported by the Deus ex Machina (DEM): Symbiotic technology for societal efficiency gains - NORTE-01-0145-FEDER-00002

In Sickness and In Health: Understanding the Effects of Marriage on Health

My DissertationDespite substantial research, how marriage reduces mortality remains unclear. Using a novel data set of over 150,000 elderly couples developed from the Medicare claims and examining the impact of widowhood vs. marriage on mortality, this dissertation seeks to adjudicate among the many plausible mechanisms. First, I exploit the variation between diseases in how responsive those diseases are to putative intervening processes to test which hypotheses can explain patterns of relative mortality. I find that in general the less healthy a person is, the less responsive they are to the death of a spouse – the most enduring mortality effects of spousal death are found among the healthiest elderly. Thus, support is found for models in which marriage provides immediate instrumental help; marriage does not appear to improve health by improving habits or by increasing some other stock of health capital that inheres in patients after the death of their spouse. The major mortality benefits of marriage also are not mediated via direct emotional or physiological effects, nor are they an artifact of selection or shared environment. Second, I show that the married appear to choose better inpatient hospital care, as measured in a number of different ways. They then have longer lengths of stay than the widowed, but do not appear to receive differential quality of care given the provider chosen. In a final chapter, I argue that relationships improve health by serving as a form of general capital, most useful when individuals face a wide variety of choices about their health.National Research Service Award Grant 5 T32 GM07281 Population Research Center has also provided me with support as a predoctoral fellow, through National Research Service Award Grant T32-AG00243http://deepblue.lib.umich.edu/bitstream/2027.42/61424/27/Chapter_1_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/26/Chapter_2_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/25/Chapter_3_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/24/Chapter_4_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/23/Chapter_5_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/22/Appendix_A_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/21/Original_Appendices_B_and_C.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/10/Bibliography.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/28/Front_Matter.pd

Survivorship Will Be the Defining Challenge of Critical Care in the 21st Century

In an invited editorial, I argue that critical care is facing a cross-roads. We can now save many patients lives. But we need to broaden our sense of our mission to include understanding, caring for, and improving, the lives of those many patients who survive critical illnessGrant Support: By the National Institutes of Health (grant K08HL091249).http://deepblue.lib.umich.edu/bitstream/2027.42/77540/1/10.Annals.Survivorship.Editorial.pd