Estimating Anesthesia Time Using the Medicare Claim: A Validation Study

INTRODUCTION: Procedure length is a fundamental variable associated with quality of care, though seldom studied on a large scale. The authors sought to estimate procedure length through information obtained in the anesthesia claim submitted to Medicare to validate this method for future studies. METHODS: The Obesity and Surgical Outcomes Study enlisted 47 hospitals located across New York, Texas, and Illinois to study patients undergoing hip, knee, colon, and thoracotomy procedures. A total of 15,914 charts were abstracted to determine body mass index and initial patient physiology. Included in this abstraction were induction, cut, close, and recovery room times. This chart information was merged to Medicare claims that included anesthesia Part B billing information. Correlations between chart times and claim times were analyzed, models developed, and median absolute differences in minutes calculated. RESULTS: Of the 15,914 eligible patients, there were 14,369 for whom both chart and claim times were available for analysis. For these 14,369, the Spearman correlation between chart and claim time was 0.94 (95% CI 0.94, 0.95), and the median absolute difference between chart and claim time was only 5 min (95% CI: 5.0, 5.5). The anesthesia claim can also be used to estimate surgical procedure length, with only a modest increase in error. CONCLUSION: The anesthesia bill found in Medicare claims provides an excellent source of information for studying surgery time on a vast scale throughout the United States. However, errors in both chart abstraction and anesthesia claims can occur. Care must be taken in the handling of outliers in these data

Obesity and Readmission in Elderly Surgical Patients

BACKGROUND: Reducing readmissions has become a focus in efforts by Medicare to improve health care quality and reduce costs. This study aimed to determine whether causes for readmission differed between obese and nonobese patients, possibly allowing for targeted interventions. METHODS: A matched case control study of Medicare patients admitted between 2002 and 2006 who were readmitted after hip or knee surgery, colectomy, or thoracotomy was performed. Patients were matched exactly for procedure, while also balancing on hospital, age, and sex. Conditional logistic regression was used to study the odds of readmission for very obese cases (body mass index \u3e35 kg/m2) versus normal weight patients (body mass index of 20-30 kg/m2) after also controlling for race, transfer-in and emergency status, and comorbidities. RESULTS: Among 15,914 patient admissions, we identified 1,380 readmitted patients and 2,760 controls. The risk of readmission was increased for obese compared to nonobese patients both before and after controlling for comorbidities (before: odds ratio, 1.35; P = .003; after: odds ratio, 1.25; P = .04). Reasons for readmission varied by procedure but were not different by body mass index category. CONCLUSION: Obese patients have an increased risk of readmission, yet the reasons for readmission in obese patients appear to be similar to those for nonobese patients, suggesting that improved postdischarge management for the obese cannot focus on a few specific causes of readmission but must instead provide a broad range of interventions

Infections and antimicrobial prescribing in patients hospitalized with coronavirus disease 2019 (COVID-19) during the first pandemic wave

Abstract Objective: To evaluate the rate of coinfections and secondary infections seen in hospitalized patients with COVID-19 and antimicrobial prescribing patterns. Methods: This single-center, retrospective study included all patients aged ≥18 years admitted with COVID-19 for at least 24 hours to a 280-bed, academic, tertiary-care hospital between March 1, 2020, and August 31, 2020. Coinfections, secondary infections, and antimicrobials prescribed for these patients were collected. Results: In total, 331 patients with a confirmed diagnosis of COVID-19 were evaluated. No additional cases were identified in 281 (84.9%) patients, whereas 50 (15.1%) had at least 1 infection. In total, of 50 patients (15.1%) who were diagnosed with coinfection or secondary infection had bacteremia, pneumonia, and/or urinary tract infections. Patients who had positive cultures, who were admitted to the ICU, who required supplemental oxygen, or who were transferred from another hospital for higher level of care were more likely to have infections. The most commonly used antimicrobials were azithromycin (75.2%) and ceftriaxone (64.9%). Antimicrobials were prescribed appropriately for 55% of patients. Conclusions: Coinfection and secondary infections are common in patients who are critically ill with COVID-19 at hospital admission. Clinicians should consider starting antimicrobial therapy in critically ill patients while limiting antimicrobial use in patients who are not critically ill

Patient and Provider Demographics and the Management of Genitourinary Tract Infections in the Emergency Department

Introduction. Urinary tract infections (UTIs) and sexually transmitted infections (STIs) can have overlapping signs, symptoms, and findings on urinalysis. Our objective was to determine if patient or provider demographics are associated with differences in the diagnosis and management of UTIs and STIs in the emergency department (ED). Methods. We analyzed 38,062 ED patient encounters from a single healthcare system between April 18, 2014, and March 7, 2017. All encounters were women ≥18 years of age and not admitted to the hospital. We performed logistic regression using patient and provider demographics, laboratory testing results, ED triage data, and ED diagnoses. Results. The patient’s age, race, and marital status were not associated with having an ED UTI diagnosis with a urine culture ≥10,000 colony forming units (CFUs)/mL (vs. <10,000 CFUs/mL). Patient race and the sex of the ED provider were not associated with differences in empiric antibiotic treatment for gonorrhea and chlamydia during the ED encounter. Patient’s race and the sex of the ED provider were also not associated with discordance between empiric antibiotic therapy given in the ED and the results of gonorrhea and chlamydia tests that resulted following the ED encounter. Conclusion. In our multivariate analyses, we did not observe that the patient’s race resulted in significant differences in the diagnosis of UTIs with bacteriuria ≥10,000 CFU/mL or differences in the empiric treatment of gonorrhea and chlamydia infections among those tested for the infection in the ED. The patient’s age and marital status, but not the provider’s sex, were significantly associated with differences in the management of gonorrhea and chlamydia

Association of Vital Signs and Process Outcomes in Emergency Department Patients

Introduction: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients.Methods: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality.Results: Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours.Conclusion: In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting

Association of Vital Signs and Process Outcomes in Emergency Department Patients

Introduction: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients. Methods: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality. Results: Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours. Conclusion: In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting

Factors influencing receipt and time to treatment of immunotherapy relative to chemotherapy in stage III and stage IV melanoma

Abstract Background Immunotherapies have changed the landscape of late‐stage melanoma; however, data evaluating timely access to immunotherapy are lacking. Methods A retrospective cohort study utilizing the National Cancer Database was conducted. Stage III and IV melanoma cases diagnosed between 2011 and 2018 that received systemic treatment with either immunotherapy or chemotherapy were included. Chemotherapy included BRAF/MEK inhibitors. Multivariable logistic regression models were utilized to evaluate factors associated with the likelihood of receiving immunotherapy as primary systemic treatment relative to chemotherapy; additionally, Cox proportional hazards models were utilized to incorporate time from diagnosis to primary systemic therapy into the analysis. Results The study population was comprised of 14,446 cases. The cohort included 12,053 (83.4%) immunotherapy and 2393 (16.6%) chemotherapy cases. In multivariable logistic regression analysis, factors significantly associated with immunotherapy receipt included population density, circle distance, year of diagnosis, Breslow thickness, and cancer stage. Immunotherapy timing was evaluated using multivariable Cox regression analysis. Minorities were less likely to receive timely immunotherapy than non‐Hispanic Whites (HR 0.83, CI 0.74–0.93, p = 0.001). Patients at circle distances of 10–49 miles (HR 0.94, CI 0.89–0.99, p = 0.02) and ≥50 miles (HR 0.83, CI 0.77–0.90, p < 0.001) were less likely to receive timely immunotherapy. Conclusion Patients traveling ≥10 miles and minorities have a decreased likelihood of receiving timely immunotherapy administration for primary systemic treatment. Future research is needed to identify what barriers and approaches can be leveraged to address these inequities