Hospital characteristics associated with adverse events and substandard care

To explore the epidemiology of adverse events (AEs), which were defined as injuries due to medical treatment, and that subset of AEs caused by negligence, we studied interhospital variation in these outcomes in a sample of 31,000 medical records drawn from a random selection of 51 hospitals in New York in 1984. We found a substantial variation in both AE rates (0.2% to 7.9%; mean, 3.2%) and the percentage of AEs due to negligence (1% to 60%; mean, 24.9%) among hospitals. Univariate analyses of AEs revealed that primary teaching institutions had significantly higher rates (4.1%) and rural hospitals had significantly lower ones (1.0%). The percentage of AEs due to negligence was lower in primary teaching (10.7%) and for-profit (9.5%) hospitals and was significantly higher in hospitals with predominantly (greater than 80%) minority patients who had been discharged (37%). These findings were corroborated by multivariate analysis. Our results suggest that AEs and negligence are not randomly distributed and that certain types of hospitals have significantly higher rates of injuries due to substandard care. These observations may represent an important improvement on existing measures of quality because they take into account the fact that some hospitals' populations may be at risk of suffering a poor outcome.     

The economic consequences of medical injuries. Implications for a no-fault insurance plan.

BACKGROUND--There has been little research into the actual economic consequences of medical injuries. This inhibits informed discussion of alternatives to malpractice litigation. For example, the cost of no-fault medical accident insurance has been thought to be prohibitive. METHOD--As part of a comprehensive analysis of medical injury and litigation, we interviewed a random sample of 794 individuals who had suffered medical adverse events in New York hospitals in 1984 and used their responses to calculate the cost of injuries. We then estimated the costs of a simulated no-fault insurance program that would operate as a second payer to direct insurance sources and would compensate for all financial losses attributed to medical injury. RESULTS--The estimated costs that would be paid by a simulated no-fault program were $161 million for medical care, $276 million for lost wages, and $441 million in lost household production, or a total of $878 million in 1989 dollars for the cohort of patients who were injured in 1984. CONCLUSION--Although our estimate does not include administrative costs, it nonetheless indicates that a no-fault program would not be notably costlier than the more than $1 billion New York physicians now spend annually on malpractice insurance.     

Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes

CONTEXT: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture. OBJECTIVES: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. DESIGN: Prospective study with data obtained from medical records and through structured interviews with patients and proxies. SETTING AND PARTICIPANTS: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998. MAIN OUTCOME MEASURES: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors. RESULTS: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average. CONCLUSIONS: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.     

Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome

To investigate the association between insurance status and condition on admission, resource use, and in-hospital mortality, we analyzed discharge abstracts for 592,598 patients hospitalized in 1987 in a national sample of hospitals. In 13 of 16 age-sex-race-specific cohorts, the uninsured had a 44% to 124% higher risk of in-hospital mortality at the time of admission than did the privately insured. After controlling for this difference, the actual in-hospital death rate was 1.2 to 3.2 times higher among uninsured patients in 11 of 16 cohorts. The uninsured also were 29% to 75% less likely to undergo each of five high-cost or high-discretion procedures and 50% less likely to have normal results on tissue pathology reports for biopsies performed during five of seven different endoscopic procedures. Our results suggest that insurance status is associated with a broad spectrum of aspects of hospital care.     

Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area

Rising competitive pressures may place uninsured patients at risk for receiving fewer services than insured patients with similar medical conditions. To examine this possibility we studied the case mix, length of stay, and number of procedures for 65,032 patients listed as self-pay or free care, Blue Cross, or Medicaid at 52 hospitals in the Boston, Mass, area during 1983. We found that the overall case mix severity index (based on expected length of stay per diagnosis related group) for uninsured patients was 30% higher in public hospitals and 8% higher in major teaching hospitals compared with other institutions. Across all hospitals, the severity index of uninsured patients was similar to that of insured patients. However, after adjusting for diagnosis related group case mix, uninsured patients had, on average, 7% shorter stays (5.36 vs 5.79 days) and underwent 7% fewer procedures (1.16 vs 1.25) than Blue Cross patients, the differences varying with hospital type. Uninsured patients also had shorter stays on average than Medicaid patients (5.36 vs 5.87 days), but they underwent a similar number of procedures. These results suggest that patients who lack insurance may receive unequal treatment even after being hospitalized.     

Percutaneous transluminal coronary angioplasty in New York State. Risk factors and outcomes.

OBJECTIVE--To identify significant independent risk factors for major percutaneous transluminal coronary angioplasty outcomes. DESIGN--Retrospective analysis using univariate and logistic regression analysis to identify significant independent risk factors for adverse outcomes. SETTING--All 31 hospitals performing percutaneous transluminal coronary angioplasty in New York State in 1991. PATIENTS--All 5827 patients undergoing percutaneous transluminal coronary angioplasty between January 1, 1991, and June 30, 1991, in New York State. MAIN OUTCOME MEASURES--In-hospital mortality, major complication(s) (in-hospital mortality, myocardial infarction, and/or emergency coronary artery bypass graft), and absence of angiographic success (stenosis reduction of less than 20% on any attempted lesion or residual stenosis of at least 50% on any attempted lesion). MAIN RESULTS--Before discharge from the hospital, a total of 37 patients (0.63%) died; 67 patients (1.1%) suffered a myocardial infarction, with a mortality rate of 4.5%; and 97 patients (1.7%) underwent emergency coronary artery bypass graft surgery, with a mortality rate of 2.1% (no deaths in 85 patients who were hemodynamically stable and two deaths among 12 patients who were hemodynamically unstable). A total of 187 patients (3.2%) experienced a major complication. Angiographic success was achieved for 88% of all patients. Multivariate analysis found four independent preprocedural variables related to death: female gender, hemodynamic instability, shock, and ejection fraction. CONCLUSIONS--Percutaneous transluminal coronary angioplasty outcomes in New York compare favorably with other recent results reported in the literature. Several preprocedural variables markedly increase the incidence of adverse events.     

Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants

OBJECTIVES: (i) To determine the proportion of patients in New Zealand who claim compensation from the national no-fault compensation program after experiencing a compensable injury; and (ii) to identify characteristics of injured patients who are least likely to claim despite having sustained a compensable injury. DESIGN: We estimated the percentage of eligible patients who claim no-fault compensation by linking a national claims database (Accident Compensation Corporation) to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses were used to investigate socioeconomic and sociodemographic differences between claimants and injured non-claimants. PARTICIPANTS AND SETTING: Patients who experienced an adverse event associated with care in NZ public hospitals in 1998 and claimed compensation with the ACC, the national no-fault insurer (n = 741). Patients identified by the NZQHS as having sustained an adverse event associated with hospital care in the same year who did not file a compensation claim (n = 839). MAIN OUTCOME MEASURES: Adverse events, compensable adverse events, and compensation claims. RESULTS: Among patients judged by NZQHS reviewers to be eligible for compensation, 2.9% (6/210) claimed. Odds of claiming after an adverse event were significantly lower for patients who were elderly (odds ratio [OR], 0.20; 95% CI, 0.14-0.28), from the most deprived areas (OR, 0.36; 95% CI, 0.23-0.57), or of Ma ori or Pacific ethnicity (OR, 0.47; 95% CI, 0.32-0.69 and OR, 0.26, 95% CI, 0.11-0.58). CONCLUSIONS: Despite few apparent institutional or economic barriers, the proportion of injured patients in NZ who seek compensation after sustaining a compensable injury is very low. Hence, substantial underclaiming occurs in both negligence and no-fault systems. The disproportionately low propensity of elderly, poor and minority patients to seek compensation also appears to be pervasive.     

The association of payer with utilization of cardiac procedures in Massachusetts

To investigate the importance of the payer in the utilization of in-hospital cardiac procedures, we examined the care of 37,994 patients with Medicaid, private insurance, or no insurance who were admitted to Massachusetts hospitals in 1985 with circulatory disorders or chest pain. Using logistic regression to control for demographic, clinical, and hospital factors, we found that the odds that privately insured patients received angiography were 80% higher than uninsured patients; the odds were 40% higher for bypass grafting and 28% higher for angioplasty. Medicaid patients experienced odds similar to those of uninsured patients for receiving angiography and bypass, but had 48% lower odds of receiving angioplasty. In addition, the odds for Medicaid patients were lower than for privately insured patients for all three cardiac procedures. These findings suggest that insurance status is associated with the utilization of cardiac procedures. Future studies should determine the implications these findings have for appropriateness and outcome and whether interventions might improve care.     

The emergency department as a pathway to admission for poor and high-cost patients

BACKGROUND.--To determine the importance of the emergency department as the means of access to the hospital for the poor and the fiscal implications of providing these services, we examined the relationship between patients' socioeconomic status and admission via the emergency department. We also determined the association between entering the hospital via the emergency department and hospital resource use. METHODS.--We conducted a study of 20,089 patients admitted to five Massachusetts hospitals (three community, two tertiary care) during a 6-month period. We determined the proportions of patients within various socioeconomic and disease groupings who entered through the emergency department. We compared length of stay and charges for patients admitted through the emergency department with those for patients admitted through other routes. RESULTS.--Overall, 51% of patients entered via the emergency department. Elderly patients (age greater than 65 years; odds ratio, 1.87) and patients with lower socioeconomic status as measured by income, occupation, and education (odds ratios, 2.38, 1.47, and 1.69, respectively) were more likely to enter the hospital via the emergency department than other patients. After adjustment for diagnosis related group, severity as measured by DRGSCALE, and socioeconomic status as measured by income, and excluding outliers, patients admitted via the emergency department stayed 27% longer and incurred 13% higher charges than other patients (P less than .001). CONCLUSIONS.--Our data indicate that patients with lower socioeconomic status are more likely than other patients to use the emergency department as their means of access to the hospital and that patients admitted via the emergency department use far more resources than patients in the same diagnosis related group admitted by other means. Hospitals that make emergency department services more available may be more likely to hospitalize socioeconomically disadvantaged patients and may be at a substantial financial disadvantage under per-case reimbursement systems such as Medicare.     

上海市社区精神分裂症患者社会经济状况及影响因素分析

目的 调查上海市社区精神分裂症患者的工作、经济和生活状态,并探讨相关人口学影响因素.方法 使用自编患者社会经济基本状况调查表,调查基于重性精神障碍管理系统、随机抽样选取的社区精神分裂症患者,了解其社会经济状况.结果 入组社区精神分裂症患者样本333例(男性183例,女性150例).患者中72.8％为无业,74.3％月收...     

Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates

This study analyzes data from New York State's new Cardiac Surgery Reporting System, which contains information about cardiac preoperative risk factors, postoperative complications, and hospital discharge. The purposes of the study were to determine the set of significant clinical risk factors and to identify cardiac surgical centers most likely to have serious quality-of-care problems. Significant risk factors for in-hospital death were age, gender, ejection fraction, previous myocardial infarction, number of open heart operations in previous admissions, diabetes requiring medication, dialysis dependence, disasters (acute structural defect, renal failure, cardiogenic shock, gunshot), unstable angina, intractable congestive heart failure, left main trunk narrowed more than 90%, and type of operation performed. Four of the 28 hospitals had significantly higher mortality rates than expected, given the risk factors of their patients. Subsequent site visits and medical record reviews confirmed that these facilities had high percentages of quality-of-care problems among cases resulting in mortality.     

Needlestick injury among medical personnel in Accident and Emergency Department of two teaching hospitals

Needlestick injury has been recognized as one of the occupational hazards which results in transmission of bloodborne pathogens. A cross-sectional study was carried out among 136 health care workers in the Accident and Emergency Department of two teaching hospitals from August to November 2003 to determine the prevalence of cases and episodes of needlestick injury. In addition, this study also assessed the level of knowledge of blood-borne diseases and Universal Precautions, risk perception on the practice of Universal Precautions and to find out factors contributing to needlestick injury. Prevalence of needlestick injury among the health care workers in the two hospitals were found to be 31.6% (N = 43) and 52.9% (N = 87) respectively. Among different job categories, medical assistants appeared to face the highest risk of needlestick injury. Factors associated with needlestick injury included shorter tenure in one's job (p < 0.05). Findings of this study support the hypothesis that health care workers are at risk of needlestick injury while performing procedures on patients. Therefore, comprehensive infection control strategies should be applied to effectively reduce the risk of needlestick injury.     

Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.

OBJECTIVE--To determine whether uninsured and Medicaid patients have higher rates of avoidable hospitalizations than do insured patients. DESIGN--We used 1987 computerized hospital discharge data to select a cross-sectional sample of hospitalized patients. Population estimates from the Current Population Survey were used to estimate rates of admission, standardized for age and sex. SETTING--Nonfederal acute care hospitals in Massachusetts and Maryland. PATIENTS--All patients under 65 years of age who were uninsured, privately insured, or insured by Medicaid. Hospitalizations for obstetric and psychiatric conditions were excluded. MAIN OUTCOME MEASURES--Relative risk of admission for 12 avoidable hospital conditions (AHCs) identified by a physician panel. RESULTS--Uninsured and Medicaid patients were more likely than insured patients to be hospitalized for AHCs. Rates for uninsured patients were significantly greater than for privately insured patients in Massachusetts for 10 of 12 individual AHCs, and in Maryland for five of 12 AHCs. After adjustment for baseline utilization, the results were statistically significant for 10 of 12 AHCs in Massachusetts and seven of 12 AHCs in Maryland. For Medicaid patients, rates were significantly greater than for privately insured patients for all AHCs in each state before adjustment, and for nine of 12 and seven of 12 AHCs in each state, respectively, after adjustment for baseline utilization. CONCLUSION--Our findings suggest that patients who are uninsured or who have Medicaid coverage have higher rates of hospitalization for conditions that can often be treated out of hospital or avoided altogether. Our approach is potentially useful for routine monitoring of access and quality of care for selected groups of patients.     

基于Apriori算法分析2021年山东省医疗器械不良事件的关联性

目的 医疗器械不良事件监测是医疗器械上市后风险管理的重要手段。本研究旨在基于Apriori算法分析2021年山东省医疗器械不良事件的关联性。方法 对2021年山东省各监测机构上报的63 041起不良伤害事件,按广义医疗器械分类划分为三类(无源医疗器械、有源医疗器械以及体外诊断试剂)医疗器械不良事件进行描述分析。采用关联规则挖掘中的Apriori模型,挖掘出与不良事件相关的器械类别、使用科室、医院类别、是否超期使用以及上报单位所属地区,探索医疗器械不良事件关联风险。结果 不良事件中包含有源医疗器械20 564起、无源医疗器械42 181起及体外诊断试剂296起。其中,无源医疗器械不良事件发生最多的地级市为烟台市(5 711起)、科室为手术室(835起)、医院类别为二级综合医院(5 320起);有源医疗器械不良事件发生最多的地级市为济南市(2 271起)、科室为手术室(196起)、医院类别为三级综合医院(1 108起);体外诊断试剂不良事件发生最多的地级市为烟台市(42起)、科室为儿科(6起)、医院类别为一级医院(42起)。根据关联规则可知,一级医院中卫生院使用未超期无源器械关联规则支持度...     

Differences in hospital resource allocation among sick newborns according to insurance coverage

OBJECTIVE--To assess whether newborns' insurance coverage was associated with differences in the allocation of hospital services. DESIGN--Retrospective analysis of computerized hospital discharge data, comparing resource allocation among newborns according to insurance status, controlling for race/ethnicity, diagnoses, hospital characteristics (ownership, teaching status, nursery level), and disposition. SETTING--All California civilian acute-care hospitals. PATIENTS--Population-based sample, excluding out-of-hospital and military hospital births. Resource allocation was studied among all newborns discharged in 1987 with evidence of serious problems (N = 29,751). MAIN OUTCOME MEASURES--Length of stay, total charges, and charges per day. RESULTS--Sick newborns without insurance received fewer inpatient services than comparable privately insured newborns with either indemnity or prepaid coverage. This pattern was observed across all hospital ownership types. Mean stay was 15.7 days for all privately insured newborns (15.6 days for those with indemnity and 15.7 days for those with prepaid coverage), 14.8 days for Medicaid-covered newborns, and 13.2 days for uninsured newborns (P less than .001). Length of stay, total charges, and charges per day were 16%, 28%, and 10% less, respectively, for the uninsured than for all privately insured newborns (P less than .001). Resources for newborns covered by Medicaid were generally greater than for the uninsured and less than for the privately insured. Both uninsured and Medicaid-covered newborns were found to have more severe medical problems than the privately insured. CONCLUSIONS--The findings cannot be explained by differences in medical need or by differences in non-medically indicated services; they constitute prima facie evidence of inequities that need to be addressed by policy changes.     

湖南省居民医疗保险未参保情况及其影响因素

目的：了解湖南省城乡居民医疗保险覆盖率及居民未参保的影响因素,为达到人人享有卫生保障提供决 策依据。方法：采用多阶段分层整群随机抽样的方法,将湖南省122个县市划分为农村和城市两层,每层中抽取7个 县区;每个县区抽取5个乡镇或街道;最后每个乡镇或街道抽取2个行政村(居委会),采用系统抽样方法从每个行政 村(居委会)抽取户,对抽中户的常住人口逐一进行询问调查。采用复杂抽样权重估算居民参保率及95% CI,采用多因 素logistic回归分析未参保的影响因素。结果：调查人群医疗保险覆盖率达95.76%(95% CI：93.04%~98.49%),4.24%(95% CI：1.51%~6.96%)的居民未参加任何保险,特别是18岁以下城市居民未参保率高达10.17%。年龄、家庭人均收入、是 否有慢性疾病与城乡居民未参保相关(P<0.05)。结论：为实现2020 年人人享有卫生保障的目标,社会医疗保险部门应 采取措施进一步提高居民的参保率。     

精神分裂症住院患者危险行为的影响因素分析

目的 探索影响精神分裂症住院患者发生危险行为的相关影响因素。方法 采用回顾性研究方法,在北京市根据地理分布采用方便抽样的方法选取4个区中5家精神专科医院,将2016年1月至10月住院的625例精神分裂症患者作为调查对象,使用自制的调查问卷进行调查,评估分析患者危险行为的发生及其相关影响因素。结果 单因素分析显示,与无危险组比较,危险行为组中性别、年龄阶段、家庭邻里关系、工作状态、应激生活事件、精神症状、服药情况、就医态度、既往威胁性言语等方面差异有统计学意义(P<0.05)。多因素Logistic 回归分析显示,年龄(OR=0.62,P=0.017)、生活应激事件(OR=2.08,P=0.001)、幻觉妄想(OR=1.77,P=0.026)、怪异行为(OR=1.61,P=0.02)、就医态度(OR=2.60,P=0.029)、既往威胁性言语(OR=6.77,P<0.001)与危险行为相关。结论 45岁以下、幻觉妄想、怪异行为、被动就医、生活应激事件、既往威胁性言语是精神分裂症住院患者发生危险行为的主要相关因素。     

A profile of the medically uninsured in Georgia

The provision of health care to the growing number of persons uninsured against medical expenses affects Georgia doctors, hospitals, and state and local government at all levels. While much is known nationally about the uninsured, there are no good data about this group in Georgia. This study uses U.S. Census Bureau data to provide a demographic profile of Georgians who lack health insurance and to identify groups at particular risk for being uninsured. Approximately 950,000 (17.7%) of non-elderly Georgia residents are uninsured, compared to 37 million (17.6%) in the U.S. as a whole. As is true generally in the U.S., those in Georgia who are poor, young, non-white, and in families with a female head are at greatest risk. Of particular note are the poor in Georgia with incomes from 50% to 100% of the federal poverty level (55.2% uninsured). This population deserves the special attention of all involved in finding a solution to this problem.     

广州市越秀区城市居民社会经济状况和心血管病危险因素的关系研究

目的：探讨广州市越秀区城市居民社会经济状况(SES)和心血管病危险因素之间的关系。方法：采用多阶段分层抽样确定样本。研究内容为社会经济状况(教育程度、职业、收入及婚姻状况)、身高、体重、腰围和血压。分析方法包括Spearman等级相关分析，方差分析及Logistic回归分析等。结果：(1)年龄和SES因子调整后，与仅是年龄调整后的分析结果不同。在4个SES指标中，婚姻状况是最有影响力的指标，单身人士(不论男女)比有配偶者更容易发生肥胖；不同职业人群发生肥胖的危险性也不同，且单身男性更易发生腹部肥胖。(2)综合的SES与心血管病危险因素显著相关，SES每增加一个等级，发生肥胖的危险是原来的1．09倍(95％CI=1．01—1．16)，发生高血压的危险是原来的0．86倍(95％CI=0．79—0．95)。结论：在SES中，婚姻状况是与最多危险因素相关的指标，是最普遍的关联因子；受教育水平并不是最重要的SES指标，但教育水平的影响更稳定；收入与心血管病危险因素的关联不明显。职业与高血压、肥胖无显著关联。社会经济状况较好的人存在低水平的高血压危险性和高水平的肥胖危险性。社会经济状况与心血管病危险因素的关联在男女之间不一致。     

新疆维吾尔族早发冠心病患者疾病认知率的影响因素分析

目的：探讨新疆地区维吾尔族早发冠心病患者对冠心病相关知识的认知率及影响认知的因素,以指导对患者进行个性化健康宣传教育工作。方法随机抽取我院门诊及住院治疗的120例维吾尔族早发冠心病患者作为调查对象,使用自行设计的调查问卷进行调查,分析调查对象对冠心病相关知识知晓率及其影响因素。结果维吾尔族早发冠心病患者对冠心病相关知识的认知率相对较低,平均得分为（27.17±6.12）分,平均得分率为45.32%;不同性别、文化程度、病程、收入水平、报销方式、婚姻状况、家庭关心程度之间在疾病认知水平上差异有统计学意义（P <0.05）;路径分析结果显示：影响维吾尔族早发冠心病患者认知情况的因素从大到小为：文化程度、报销方式、收入水平、家属关心、婚姻以及性别。结论对于低学历、低收入、公费、家庭关心程度低、女性的维吾尔族早发冠心病患者应引起足够的重视,在入院时即进行规范的健康教育,从而较快、较好地提高新疆维吾尔族早发冠心病患者对此疾病的认知水平,改善预后、预后再次发生,减少医疗费用等。