Validity of different algorithmic methods to identify hospital readmissions from routinely coded medical data.

BACKGROUND Hospital readmission rates are used for quality and pay-for-performance initiatives. To identify readmissions from administrative data, two commonly employed methods are focusing either on unplanned readmissions (used by the Centers for Medicare & Medicaid Services, CMS) or potentially avoidable readmissions (used by commercial vendors such as SQLape or 3 M). However, it is not known which of these methods has higher criterion validity and can more accurately identify actually avoidable readmissions. OBJECTIVES A manual record review based on data from seven hospitals was used to compare the validity of the methods by CMS and SQLape. METHODS Seven independent reviewers reviewed 738 single inpatient stays. The sensitivity, specificity, positive predictive value (PPV), and F1 score were examined to characterize the ability of an original CMS method, an adapted version of the CMS method, and the SQLape method to identify unplanned, potentially avoidable, and actually avoidable readmissions. RESULTS Both versions of the CMS method had greater sensitivity (92/86% vs. 62%) and a higher PPV (84/91% vs. 71%) than the SQLape method, in terms of identifying their outcomes of interest (unplanned vs. potentially avoidable readmissions, respectively). To distinguish actually avoidable readmissions, the two versions of the CMS method again displayed higher sensitivity (90/85% vs. 66%), although the PPV did not differ significantly between the different methods. CONCLUSIONS Thus, the CMS method has both higher criterion validity and greater sensitivity for identifying actually avoidable readmissions, compared with the SQLape method. Consequently, the CMS method should primarily be used for quality initiatives

Predictors for shorter and longer length of hospital stay outliers: a retrospective case-control study of 8247 patients at a university hospital trauma department

BACKGROUND Providing efficient healthcare is important for hospitals. Shorter and longer length of hospital stay (LOS) outliers influence financial results and reimbursement. The objective of this study was to identify independent diagnosis related group (DRG)-related risk factors for shorter and longer LOS outlier status. METHODS A retrospective case-control study was conducted at a Swiss level 1 trauma centre between January 2012 and December 2014. The study included all patients with available information on LOS based on DRG. Many predictor variables were tested. The outcome variable was the DRG-based LOS. Logistic regression models were fitted for shorter and longer LOS outliers, with a significance level of <1%. RESULTS A total of 8247 patients were analysed, of whom inliers were more frequent than shorter and longer LOS outliers (n = 5838 [70.8%] vs n = 1996 [24.2%] vs n = 413 [5.0%]). Predictors for shorter LOS outliers were death (odds ratio [OR] 4.89, 95% confidence interval [CI] 3.27-7.31), concussion (OR 4.87, 95% CI 4.20-5.63) and psychiatric disease (OR 1.85, 95% CI 1.46-2.34). Predictors for longer LOS outliers were age ≥65 years (OR 1.74, 95% CI 1.31-2.30), number of diagnoses ≥5 (OR 2.07, 95% CI 1.52-2.81), comorbidity (OR 1.75, 95% CI 1.28-2.40), number of surgical procedures (OR 1.76, 95% CI 1.36-2.28), complication perioperatively (OR 1.69, 95% CI 1.24-2.30), infection (OR 2.66, 95% CI 1.57-4.49]), concussion (OR 1.52, 95% CI 1.14-2.01) and urinary tract infection (OR 2.34, 95% CI 1.61-3.41). CONCLUSION This large study showed that LOS outliers, especially shorter LOS outliers, are relatively common. Patients who died, or had concussion or psychiatric disease were more commonly discharged early. Patients weremore often discharged late if they were aged ≥65 years, had more diagnoses, were comorbid, had more surgical procedures, complications perioperatively, infection, concussion and urinary tract infection. For hospitals, this can help raise awareness and lead to better management of specific diagnoses in order to avoid monetary deficits. For the public health sector, this information may be considered in future revisions of the DRG

ASA score and procedure type predict complications and costs in maxillofacial reconstructive surgery: a retrospective study using a hospital administrative database

BACKGROUND Reconstruction of osseous and soft tissue defects after surgical resection of oral cavity cancers can be achieved by a single-stage procedure with a microvascular bone flap or by a two-step approach with a soft tissue flap and subsequent bone augmentation. The therapeutic approach should be selected based on the patient&rsquo;s needs. Economic pressure requires preoperative risk assessment and estimation of the postoperative course. Flat-rate reimbursement systems via diagnosis-related groups with insufficient morbidity adjustments and financial sanction of medical complications might additionally cause false incentives in the choice of treatment. OBJECTIVE This study aimed to assess the influence of the type of flap chosen for maxillofacial reconstructive surgery on the total costs. Complication rates of different types of flap surgery and their prediction by a preoperative risk assessment tool (American Society of Anesthesiologists [ASA] score) were determined. Overall, the fairness of the current reimbursement system was rated. METHODS Patient characteristics, clinical data, and data on total costs and reimbursement of patients aged 18 years and older having undergone maxillofacial reconstructive flap surgery at the University Hospital of Zurich (Switzerland) between 2012 and 2014 were analysed. The preoperative risk was classified by the ASA score. Complications were graded according to the Clavien-Dindo classification system and the comprehensive complication index (CCI). Statistical analysis included Spearman and Pearson rank correlation, Kruskal-Wallis and Mann-Whitney nonparametric tests, and linear regression analysis. RESULTS 129 patients were included in this study. Soft tissue flaps were performed in 82 patients, of which 56 were radial forearm flaps (43.4%), bone flaps in 41 patients, of which 32 were fibula flaps (24.8%), and combined flaps in 6 patients (4.7%). Patients with fibula flaps showed a significantly higher CCI and higher total costs. Higher preoperative ASA scores were significantly associated with increased length of stay, total costs and complications. Both the ASA score and reconstruction with a radial forearm flap were significant predictors of complications and total costs. Total median costs for radial forearm flaps were CHF 50,560 (reimbursement: CHF 60,851; difference: CHF 10,291) and for fibula flaps CHF 66,982 (reimbursement: CHF 58,218; difference: CHF &minus;8,764). CONCLUSION The ASA score allows a reliable preoperative assessment of patient outcomes and financial burden in maxillofacial reconstructive flap surgery. The type of flap reconstruction significantly influences complications and ultimately total costs. The current reimbursement system via diagnosis-related groups (DRGs) does not take sufficient account of this fact. Adaptations are therefore needed to prevent misplaced incentives to the detriment of patients

Are the rib fracture score and different computed tomography measures of obesity predictors for mortality in patients with rib fractures? A retrospective cohort study

BACKGROUND: There is missing knowledge about the association of obesity and mortality in patients with rib fractures. Since the global measure of obesity (body mass index [BMI]) is often unknown in trauma patients, it would be convenient to use local computed tomography (CT)-based measures (e.g., umbilical outer abdominal fat) as a surrogate. The purpose of this study was to assess (1) whether local measures of obesity and rib fractures are associated with mortality and abdominal injuries and to evaluate (2) the correlation between local and global measures of obesity. MATERIALS AND METHODS: A retrospective cohort study included all inpatients with rib fractures in 2013. The main exposure variable was the rib fracture score (RFS) (number of rib fractures, uni- or bilateral, age). Other exposure variables were CT-based measures of obesity and BMI. The primary outcome (endpoint) was in-hospital mortality. The secondary outcome consisted of abdominal injuries. Sex and comorbidities were adjusted for with logistic regression. RESULTS: Two hundred and fifty-nine patients (median age 55.0 [IQR 44.0-72.0] years) were analyzed. Mortality was 8.5%. RFS > 4 was associated with 490% increased mortality (OR$_{adjusted}$ = 5.9, 95% CI 1.9-16.6, p = 0.002). CT-based measures and BMI were not associated with mortality, rib fractures or injury of the liver. CT-based measures of obesity showed moderate correlations with BMI (e.g., umbilical outer abdominal fat: r = 0.59, p < 0.001). CONCLUSIONS: RFS > 4 was an independent risk factors for increased mortality. Local and global measures of obesity were not associated with mortality, rib fractures or liver injuries. If the BMI is not available in trauma patients, CT-based measures of obesity may be considered as a surrogate