Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic

Importance: Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients\u27 likelihood of a subsequent urologic intervention could inform decision-making in this population. Objectives: To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. Design, Setting, and Participants: This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. Main Outcomes and Measures: The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. Results: A total of 66218 unique index visits by 55314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P \u3c .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P \u3c .001) compared with patients with all other insurance types. Conclusions and Relevance: In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients

Derivation and Validation of an Inâ Hospital Mortality Prediction Model Suitable for Profiling Hospital Performance in Heart Failure

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/1/jah32925_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/2/jah32925.pd

Correction Methods, Approximate Biases, and Inference for Misclassified Data

When categorical data are misplaced into the wrong category, we say the data is affected by misclassification. This is common for data collection. It is well-known that naive estimators of category probabilities and coefficients for regression that ignore misclassification can be biased. In this dissertation, we develop methods to provide improved estimators and confidence intervals for a proportion when only a misclassified proxy is observed, and provide improved estimators and confidence intervals for regression coefficients when only misclassified covariates are observed. Following the introduction and literature review, we develop two estimators for a proportion , one which reduces the bias, and one with smaller mean square error. Then we will give two methods to find a confidence interval for a proportion, one using optimization techniques, and the other one using Fieller\u27s method. After that, we will focus on developing methods to find corrected estimators for coefficients of regression with misclassified covariates, with or without perfectly measured covariates, and with a known estimated misclassification/reclassification model. These correction methods use the score function approach, regression calibration and a mixture model. We also use Fieller\u27s method to find a confidence interval for the slope of simple regression with misclassified binary covariates. Finally, we use simulation to demonstrate the performance of our proposed methods

Use of Mechanical Ventilation Across 3 Countries

Importance: The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear. Objective: To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability. Design, setting, and participants: This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US. Exposure: The country in which IMV was received. Main outcomes and measures: The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022. Results: The study included 59 873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70 250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1 614 768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100 000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100 000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada). Conclusions and relevance: This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource

Mortality Measures to Profile Hospital Performance for Patients With Septic Shock

OBJECTIVES: Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals. PATIENTS: Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]). CONCLUSIONS: Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure

Influenza Vaccinations Among Privately and Publicly Insured Children with Asthma

Objectives: Annual influenza vaccination rates for children remain well below the Healthy People 2030 target of 70%. We aimed to compare influenza vaccination rates for children with asthma by insurance type and to identify associated factors. Methods: This cross-sectional study examined influenza vaccination rates for children with asthma by insurance type, age, year, and disease status using the Massachusetts All Payer Claims Database (2014-2018). We used multivariable logistic regression to estimate the probability of vaccination accounting for child and insurance characteristics. Results: The sample included 310,099 child-year observations for children with asthma in 2015-2018. Fewer than half of children with asthma received influenza vaccinations; 51.2% among privately insured and 45.1% among Medicaid insured. Risk modeling reduced, but did not eliminate, this gap; privately insured children were 3.4 percentage points (pp) more likely to receive an influenza vaccination than Medicaid insured children (95% CI: 2.6pp to 4.2pp). Risk modeling also found persistent asthma was associated with more vaccinations (7.5pp higher; 95% CI: 7.0pp to 8.0pp), as was younger age. The regression-adjusted probability of influenza vaccination in a non-office setting was 3.2 pp higher in 2018 than 2015 (95% CI: 2.2p to 4.2pp), and significantly lower for children with persistent asthma and with Medicaid. Conclusions: Despite clear recommendations for annual influenza vaccinations for children with asthma, low rates persist, particularly for children with Medicaid. Offering vaccines in non-office settings such as retail pharmacies may reduce barriers, but we did not observe increased vaccination rates in the first years after this policy change. Keywords: Medicaid; asthma; vaccination

Variation in Pediatric Asthmonia Diagnosis and Outcomes among Hospitalized Children

Rationale: Although \u3c5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals asthma-pneumonia co-diagnosis is so common that the term asthmonia is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted healthcare costs and contribute to unnecessary antibiotic prescribing. Objective: To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals\u27 asthmonia diagnosis rates and clinical outcomes. Methods: We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015-6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio (MOR) was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes. Results: Of 24606 asthma exacerbations, 19402 (78.9%) were diagnosed with asthma alone and 5204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (IQR:16.2-27.2%, range:8.4-55.9%). The MOR was 1.75 (95% CI:1.63-1.86). Compared to hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, non-teaching, rural hospitals with minimal subspecialty support (all p\u3c0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic utilization, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission. Conclusions: Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, non-teaching hospitals with minimal pediatric specialty support

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children\u27s hospitals in the United States

BACKGROUND: Children may be hospitalized at general hospitals or freestanding children\u27s hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts. OBJECTIVE: To describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding children\u27s hospitals in the United States. DESIGN, PATIENTS, AND SETTING: Cross-sectional study of hospitalizations in the United States among children \u3c18 years, excluding in-hospital births, using the Healthcare Cost and Utilization Project\u27s 2012 Kids\u27 Inpatient Database. MEASUREMENT: We examined differences between hospitalizations at general and freestanding children\u27s hospitals, applying weights to generate national estimates. Reasons for hospitalization were categorized using a pediatric grouper, and differences in hospital volumes were assessed for common diagnoses. RESULTS: A total of 1,407,822 (standard deviation 50,456) hospitalizations occurred at general hospitals, representing 71.7% of pediatric hospitalizations. Hospitalizations at general hospitals accounted for 63.6% of hospital days and 50.0% of pediatric inpatient healthcare costs. Median volumes of pediatric hospitalizations, per hospital, were significantly lower at general hospitals than freestanding children\u27s hospitals for common medical and surgical diagnoses. Although the most common reasons for hospitalization were similar, the most costly conditions differed. CONCLUSIONS: In 2012, more than 70% of pediatric hospitalizations occurred at general hospitals in the United States. Differences in patterns of care at general hospitals and freestanding children\u27s hospitals may inform clinical programs, research, and quality improvement efforts

Use of Vasoactive Medications after Cardiac Surgery in the United States

Rationale: Patients undergoing cardiac surgery often require vasopressor or inotropic (\u27vasoactive\u27) medications, but patterns of postoperative use are not well described. Objectives: This study aimed to describe vasoactive medication administration throughout hospitalization for cardiac surgery, to identify patient and hospital-level factors associated with postoperative use, and to quantify variation in treatment patterns among hospitals. Methods: Retrospective study using the Premier Healthcare Database. The cohort included adult patients who underwent coronary artery bypass grafting or open valve repair/replacement (or in combination) January 1, 2016 - June 30, 2018. Primary outcome was receipt of vasoactive medication(s) on the first postoperative day (POD1). We identified patient and hospital-level factors associated with receipt of vasoactive medications using multilevel mixed-effects logistic regression modeling. We calculated adjusted median odds ratios (AMORs) to determine the extent to which receipt of vasoactive medications on POD1 was determined by each hospital, then calculated quotients of Akaike Information Criteria (AIC) to compare the relative contributions of patient and hospital characteristics and individual hospitals to observed variation. Results: Among 104,963 adults in 294 hospitals, 95,992 (92.2%) received vasoactive medication(s) during hospitalization; 30,851 (29.7%) received treatment on POD1, most commonly norepinephrine (n=11,427, 37.0%). A median of 29.0% (range 0.0-94.4%) of patients in each hospital received vasoactive drug(s) on POD1. After adjustment, hospital of admission was associated with two-fold increased odds of receipt of any vasoactive medication on POD1 (AMOR 2.07, 95% CI 1.93-2.21). Admitting hospital contributed more to observed variation in POD1 vasoactive medication use than patient or hospital characteristics (quotients of AIC 0.58, 0.44, and \u3c0.001, respectively). Conclusions: Nearly all cardiac surgical patients receive vasoactive medications during hospitalization, however only a third receive treatment on POD1, with significant variability by institution. Further research is needed to understand the causes of variability across hospitals and whether these differences are associated with outcomes