First name
Jeffrey
Middle name
H
Last name
Silber

Title

Failure to Rescue as an Outcome Metric for Pediatric and Congenital Cardiac Catheterization Laboratory Programs: Analysis of Data From the IMPACT Registry.

Year of Publication

2019

Number of Pages

e013151

Date Published

2019 Nov 05

ISSN Number

2047-9980

Abstract

<p><strong>Background </strong>Risk-adjusted adverse event (AE) rates have been used to measure the quality of pediatric and congenital cardiac catheterization laboratories. In other settings, failure to rescue (FTR) has demonstrated utility as a quality metric.</p>

<p><strong>Methods and Results </strong>A multicenter retrospective cohort study was performed using data from the IMPACT (Improving Adult and Congenital Treatment) Registry between January 2010 and December 2016. A modified FTR metric was developed for pediatric and congenital cardiac catheterization laboratories and then compared with pooled AEs. The associations between patient- and hospital-level factors and outcomes were evaluated using hierarchical logistic regression models. Hospital risk standardized ratios were then calculated. Rankings of risk standardized ratios for each outcome were compared to determine whether AEs and FTR identified the same high- and low-performing centers. During the study period, 77&nbsp;580 catheterizations were performed at 91 hospitals. Higher annual hospital catheterization volume was associated with lower odds of FTR (odds ratio: 0.68 per 300 cases; =0.0003). No association was seen between catheterization volume and odds of AEs. Odds of AEs were instead associated with patient- and procedure-level factors. There was no correlation between risk standardized ratio ranks for FTR and pooled AEs (=0.46). Hospital ranks by catheterization volume and FTR were associated (=-0.28, =0.01) with the largest volume hospitals having the lowest risk of FTR.</p>

<p><strong>Conclusions</strong> In contrast to AEs, FTR was not strongly associated with patient- and procedure-level factors and was significantly associated with pediatric and congenital cardiac catheterization laboratory volume. Hospital rankings based on FTR and AEs were not significantly correlated. We conclude that FTR is a complementary measure of catheterization laboratory quality and should be included in future research and quality-improvement projects.</p>

DOI

10.1161/JAHA.119.013151

Alternate Title

J Am Heart Assoc

PMID

31619106

Title

Auditing Practice Style Variation in Pediatric Inpatient Asthma Care.

Year of Publication

2016

Number of Pages

878-86

Date Published

2016 Sep 01

ISSN Number

2168-6211

Abstract

<p><strong>IMPORTANCE: </strong>Asthma is the most prevalent chronic illness among children, remaining a leading cause of pediatric hospitalizations and representing a major financial burden to many health care systems.</p>

<p><strong>OBJECTIVE: </strong>To implement a new auditing process examining whether differences in hospital practice style may be associated with potential resource savings or inefficiencies in treating pediatric asthma admissions.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>A retrospective matched-cohort design study, matched for asthma severity, compared practice patterns for patients admitted to Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System (PHIS) database. With 3 years of PHIS data on 48 887 children, an asthma template was constructed consisting of representative children hospitalized for asthma between April 1, 2011, and March 31, 2014. The template was matched with either a 1:1, 2:1, or 3:1 ratio at each of 37 tertiary care children's hospitals, depending on available sample size.</p>

<p><strong>EXPOSURE: </strong>Treatment at each PHIS hospital.</p>

<p><strong>MAIN OUTCOMESS AND MEASURES: </strong>Cost, length of stay, and intensive care unit (ICU) utilization.</p>

<p><strong>RESULTS: </strong>After matching patients (n = 9100; mean [SD] age, 7.1 [3.6] years; 3418 [37.6%] females) to the template (n = 100, mean [SD] age, 7.2 [3.7] years; 37 [37.0%] females), there was no significant difference in observable patient characteristics at the 37 hospitals meeting the matching criteria. Despite similar characteristics of the patients, we observed large and significant variation in use of the ICUs as well as in length of stay and cost. For the same template-matched populations, comparing utilization between the 12.5th percentile (lower eighth) and 87.5th percentile (upper eighth) of hospitals, median cost varied by 87% ($3157 vs $5912 per patient; P &lt; .001); total hospital length of stay varied by 47% (1.5 vs 2.2 days; P &lt; .001); and ICU utilization was 254% higher (6.5% vs 23.0%; P &lt; .001). Furthermore, the patterns of resource utilization by patient risk differed significantly across hospitals. For example, as patient risk increased one hospital displayed significantly increasing costs compared with their matched controls (comparative cost difference: lowest risk, -34.21%; highest risk, 53.27%; P &lt; .001). In contrast, another hospital displayed significantly decreasing costs relative to their matched controls as patient risk increased (comparative cost difference: lowest risk, -10.12%; highest risk, -16.85%; P = .01).</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>For children with asthma who had similar characteristics, we observed different hospital resource utilization; some values differed greatly, with important differences by initial patient risk. Through the template matching audit, hospitals and stakeholders can better understand where this excess variation occurs and can help to pinpoint practice styles that should be emulated or avoided.</p>

DOI

10.1001/jamapediatrics.2016.0911

Alternate Title

JAMA Pediatr

PMID

27398908

Title

Racial Disparities in Medicaid Asthma Hospitalizations.

Year of Publication

2016

Number of Pages

pii: e20161221

Date Published

2017 Jan

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Black children with asthma comprise one-third of all asthma patients in Medicaid. With increasing Medicaid coverage, it has become especially important to monitor Medicaid for differences in hospital practice and patient outcomes by race.</p>

<p><strong>METHODS: </strong>A multivariate matched cohort design, studying 11 079 matched pairs of children in Medicaid (black versus white matched pairs from inside the same state) admitted for asthma between January 1, 2009 and November 30, 2010 in 33 states contributing adequate Medicaid Analytic eXtract claims.</p>

<p><strong>RESULTS: </strong>Ten-day revisit rates were 3.8% in black patients versus 4.2% in white patients (P = .12); 30-day revisit and readmission rates were also not significantly different by race (10.5% in black patients versus 10.8% in white patients; P = .49). Length of stay (LOS) was also similar; both groups had a median stay of 2.0 days, with a slightly lower percentage of black patients exceeding their own state's median LOS (30.2% in black patients versus 31.8% in white patients; P = .01). The mean paired difference in LOS was 0.00 days (95% confidence interval, -0.08 to 0.08). However, ICU use was higher in black patients than white patients (22.2% versus 17.5%; P &lt; .001). After adjusting for multiple testing, only 4 states were found to differ significantly, but only in ICU use, where blacks had higher rates of use.</p>

<p><strong>CONCLUSIONS: </strong>For closely matched black and white patients, racial disparities concerning asthma admission outcomes and style of practice are small and generally nonsignificant, except for ICU use, where we observed higher rates in black patients.</p>

DOI

10.1542/peds.2016-1221

Alternate Title

Pediatrics

PMID

28025238

Title

Practice Patterns in Medicaid and Non-Medicaid Asthma Admissions.

Year of Publication

2016

Date Published

2016 Jul 6

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>With American children experiencing increased Medicaid coverage, it has become especially important to determine if practice patterns differ between Medicaid and non-Medicaid patients. Auditing such potential differences must carefully compare like patients to avoid falsely identifying suspicious practice patterns. We asked if we could observe differences in practice patterns between Medicaid and non-Medicaid patients admitted for asthma inside major children's hospitals.</p>

<p><strong>METHODS: </strong>A matched cohort design, studying 17 739 matched pairs of children (Medicaid to non-Medicaid) admitted for asthma in the same hospital between April 1, 2011 and March 31, 2014 in 40 Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System database. Patients were matched on age, sex, asthma severity, and other patient characteristics.</p>

<p><strong>RESULTS: </strong>Medicaid patient median cost was $4263 versus $4160 for non-Medicaid patients (P &lt; .001). Additionally, the median cost difference (Medicaid minus non-Medicaid) between individual pairs was only $84 (95% confidence interval: 44 to 124), and the mean cost difference was only $49 (95% confidence interval: -72 to 170). The 90th percentile costs were also similar between groups ($10 710 vs $10 948; P &lt; .07). Length of stay (LOS) was also very similar; both groups had a median stay of 1 day, with a similar percentage of patients exceeding the 90th percentile of individual hospital LOS (7.1% vs 6.7%; P = .14). ICU use was also similar (10.1% vs 10.6%; P = .12).</p>

<p><strong>CONCLUSIONS: </strong>For closely matched patients within the same hospital, Medicaid status did not importantly influence costs, LOS, or ICU use.</p>

DOI

10.1542/peds.2016-0371

Alternate Title

Pediatrics

PMID

27385812

Title

Continuity of public insurance coverage: a systematic review of the literature.

Year of Publication

2014

Number of Pages

115-37

Date Published

2014 Apr

ISSN Number

1552-6801

Abstract

<p>Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.</p>

DOI

10.1177/1077558713504245

Alternate Title

Med Care Res Rev

PMID

24227811

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