Inpatient hospital performance is associated with post-discharge sepsis mortality.

BACKGROUND: Post-discharge deaths are common in patients hospitalized for sepsis, but the drivers of post-discharge deaths are unclear. The objective of this study was to test the hypothesis that hospitals with high risk-adjusted inpatient sepsis mortality also have high post-discharge mortality, readmissions, and discharge to nursing homes. METHODS: Retrospective cohort study of age-qualifying Medicare beneficiaries with sepsis hospitalization between January 2013 and December 2014. Hospital survivors were followed for 180-days post-discharge, and mortality, readmissions, and new admission to skilled nursing facility were measured. Inpatient hospital-specific sepsis risk-adjusted mortality ratio (observed: expected) was the primary exposure. RESULTS: A total of 830,721 patients in the cohort were hospitalized for sepsis, with inpatient mortality of 20% and 90-day mortality of 48%. Higher hospital-specific sepsis risk-adjusted mortality was associated with increased 90-day post-discharge mortality (aOR 1.03 per each 0.1 increase in hospital inpatient O:E ratio, 95% CI 1.03-1.04). Higher inpatient risk adjusted mortality was also associated with increased probability of being discharged to a nursing facility (aOR 1.03, 95% CI 1.02-1.03) and 90-day readmissions (aOR 1.03, 95% CI 1.02-1.03). CONCLUSIONS: Hospitals with the highest risk-adjusted sepsis inpatient mortality also have higher post-discharge mortality and increased readmissions, suggesting that post-discharge complications are a modifiable risk that may be affected during inpatient care. Future work will seek to elucidate inpatient and healthcare practices that can reduce sepsis post-discharge complications

Qualitative study of system-level factors related to genomic implementation

PURPOSE: Research on genomic medicine integration has focused on applications at the individual level, with less attention paid to implementation within clinical settings. Therefore, we conducted a qualitative study using the Consolidated Framework for Implementation Research (CFIR) to identify system-level factors that played a role in implementation of genomic medicine within Implementing GeNomics In PracTicE (IGNITE) Network projects. METHODS: Up to four study personnel, including principal investigators and study coordinators from each of six IGNITE projects, were interviewed using a semistructured interview guide that asked interviewees to describe study site(s), progress at each site, and factors facilitating or impeding project implementation. Interviews were coded following CFIR inner-setting constructs. RESULTS: Key barriers included (1) limitations in integrating genomic data and clinical decision support tools into electronic health records, (2) physician reluctance toward genomic research participation and clinical implementation due to a limited evidence base, (3) inadequate reimbursement for genomic medicine, (4) communication among and between investigators and clinicians, and (5) lack of clinical and leadership engagement. CONCLUSION: Implementation of genomic medicine is hindered by several system-level barriers to both research and practice. Addressing these barriers may serve as important facilitators for studying and implementing genomics in practice

Intensity of Care and the Injured Older Adult: Measurement, Variability, and Outcomes Using Medicare Claims Data

Approximately 3 million Emergency Department (ED) visits and 50,000 deaths occur annually in adults over age 65, of which 50% are from falls and 13% are from motor vehicle crashes. Treatment begins in the out-of-hospital setting (Emergency Medical Services), continues in the ED, includes definitive in hospital and outpatient care, and then recovery in rehabilitation centers and via home-health providers. Older adults have four times the odds of dying in the hospital and are twice as likely to be discharged to skilled nursing facilities when compared with younger patients. The focus of this study is to evaluate the intensity of care delivered to older adults during hospitalization. We used Centers for Medicare and Medicaid Services claims (2013–2014), to identify beneficiaries with moderate and severe blunt trauma admitted through an ED (n = 683,398). First, we classified beneficiaries into low, moderate, or high intensity care using latent class methods which examined 18 procedures/interventions, ICU length of stay, and demographic and injury characteristics. Approximately 73% were classified as low intensity, 23% moderate, and 4% as high intensity care. Lower intensity aligned with increased age and reduced injury severity, while males, non-whites, and non-fall mechanisms were more common with high intensity. Second, at each hospital we calculated the average probability that patients received high intensity care (0.20; IQR:0.15–0.26). High intensity hospitals were defined as those with an average probability \u3e 0.50 (n = 77), and a greater proportion of these were non-trauma centers (93%) and located in the South (52%). Third, we examined the association between survival and intensity and found decreased odds of 30-day survival in moderate and high intensity when compared with low (OR:0.35 (95% CI:0.34, 0.36) and OR:0.07 (0.07, 0.07), respectively). Using a subdistribution hazards model to estimate survival to discharge (competing risk: death), moderate and high intensity both had decreased survival compared to low intensity (SHR:0.56 (95% CI:0.56, 0.57) and 0.21 (0.20. 0.21), respectively). This work demonstrates that although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. Care intensity is related to resources and patient preferences, is a component of quality, and should be benchmarked along with clinical outcomes