Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): a matched prospective cohort study

Purpose

Central venous catheter-associated bloodstream infections (CVC BSI) are a common and serious complication among critically ill patients on intensive care units (ICUs), but also result in a financial burden for the health care system. Our aim was to determine the additional costs and length of stay (LOS) of patients with ICU-acquired CVC BSI.

Methods

We used the surveillance method of the German nosocomial infection surveillance system (Krankenhaus Infections Surveillance System, KISS) to find cases of CVC BSI. The associated costs of CVC BSI were estimated as true costs generated within our hospital. We used a matched cohort design, comparing patients with CVC BSI and patients without BSI. The study period was from January to December 2010. Patients were matched by age, sex, and Simplified Acute Physiology Score (SAPS). The LOS in the ICU of control patients needed to be at least as long as that of CVC BSI patients before the onset of CVC BSI.

Results

We matched 40 CVC BSI patients to 40 patients without BSI. The median hospital costs for CVC BSI patients were significantly higher than for patients without BSI (60,445 € vs. 35,730 €; p = 0.006) and the CVC BSI patients stayed longer in the hospital than patients without CVC BSI (44 days vs. 30 days; p = 0.110). The median attributable costs per CVC BSI was 29,909 € (p = 0.006) and the median attributable LOS was 7 days (p = 0.006).

Conclusion

CVC BSI is associated with increased hospital costs and prolonged hospital stay. Hospital management should implement control measurements to keep the incidence of CVC BSI as low as possible.     

A regional evaluation of variation in low-severity hospital admissions

Objective

Determine patient and hospital-level variation in proportions of low-severity admissions.

Design

Retrospective cohort study.

Setting

Thirty hospitals in a large metropolitan region.

Patients

A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n=25.213) or pneumonia (n=17,996).

Measurements and main results

Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical based on clinical data abstracted from patients' medical records. Admissions were categorized as “low severity” if the predicted risk of death was less than 1%. Nearly 15% of patients (n=6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p<.001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p<.001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p<.01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors.

Conclusions

Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.     

Risk factors and mortality for nosocomial bloodstream infections in elderly patients

Objective

To determine risk factors for nosocomial bloodstream infection (BSI) and associated mortality in geriatric patients in geriatric and internal medicine wards at a university hospital.

Methods

Single-center retrospective (1992–2007), pairwise-matched (1:1-ratio) cohort study. Geriatric patients with nosocomial BSI were matched with controls without BSI on year of admission and length of hospitalization before onset of BSI. Demographic, microbiological, and clinical data are collected.

Results

One-hundred forty-two BSI occurred in 129 patients. Predominant microorganisms were Escherichia coli (23.2%), coagulase-negative Staphylococci (19.4%), Pseudomonas aeruginosa (8.4%), Staphylococcus aureus (7.1%), Klebsiella pneumoniae (5.8%) and Candida spp. (5.8%). Matching was successful for 109 cases. Compared to matched control subjects, cases were more frequently female, suffered more frequently from arthrosis, angina pectoris and pressure ulcers, had worse Activities of Daily Living-scores, had more often an intravenous or bladder catheter, and were more often bedridden. Logistic regression demonstrated presence of an intravenous catheter (odds ratio [OR] 7.5, 95% confidence interval [CI] 2.5–22.9) and being bedridden (OR 2.9, 95% CI 1.6–5.3) as independent risk factors for BSI. In univariate analysis nosocomial BSI was associated with increased mortality (22.0% vs. 11.0%; P = 0.029). After adjustment for confounding co-variates, however, nosocomial BSI was not associated with mortality (hazard ratio 1.3, 95% CI 0.6–2.6). Being bedridden and increasing age were independent risk factors for death.

Conclusion

Intravenous catheters and being bedridden are the main risk factors for nosocomial BSI. Although associated with higher mortality, this infectious complication seems not to be an independent risk factor for death in geriatric patients.     

Patterns of Hospital Performance on the Hospital-Wide 30-Day Readmission Metric: Is the Playing Field Level?

Background

Hospital performance on the 30-day hospital-wide readmission (HWR) metric as calculated by the Centers for Medicare and Medicaid Services (CMS) is currently reported as a quality measure. Focusing on patient-level factors may provide an incomplete picture of readmission risk at the hospital level to explain variations in hospital readmission rates.

Objective

To evaluate and quantify hospital-level characteristics that track with hospital performance on the current HWR metric.

Design

Retrospective cohort study.

Setting/Patients

A total of 4785 US hospitals.

Metrics

We linked publically available data on individual hospitals published by CMS on patient-level adjusted 30-day HWR rates from July 1, 2011, through June 30, 2014, to the 2014 American Hospital Association annual survey. Primary outcome was performance in the worst CMS-calculated HWR quartile. Primary hospital-level exposure variables were defined as: size (total number of beds), safety net status (top quartile of disproportionate share), academic status [member of the Association of American Medical Colleges (AAMC)], National Cancer Institute Comprehensive Cancer Center (NCI-CCC) status, and hospital services offered (e.g., transplant, hospice, emergency department). Multilevel regression was used to evaluate the association between 30-day HWR and the hospital-level factors.

Results

Hospital-level characteristics significantly associated with performing in the worst CMS-calculated HWR quartile included: safety net status [adjusted odds ratio (aOR) 1.99, 95% confidence interval (95% CI) 1.61–2.45, p < 0.001], large size (> 400 beds, aOR 1.42, 95% CI 1.07–1.90, p = 0.016), AAMC alone status (aOR 1.95, 95% CI 1.35–2.83, p < 0.001), and AAMC plus NCI-CCC status (aOR 5.16, 95% CI 2.58–10.31, p < 0.001). Hospitals with more critical care beds (aOR 1.26, 95% CI 1.02–1.56, p = 0.033), those with transplant services (aOR 2.80, 95% CI 1.48–5.31,p = 0.001), and those with emergency room services (aOR 3.37, 95% CI 1.12–10.15, p = 0.031) demonstrated significantly worse HWR performance. Hospice service (aOR 0.64, 95% CI 0.50–0.82, p < 0.001) and having a higher proportion of total discharges being surgical cases (aOR 0.62, 95% CI 0.50–0.76, p < 0.001) were associated with better performance.

Limitation

The study approach was not intended to be an alternate readmission metric to compete with the existing CMS metric, which would require a re-examination of patient-level data combined with hospital-level data.

Conclusion

A number of hospital-level characteristics (such as academic tertiary care center status) were significantly associated with worse performance on the CMS-calculated HWR metric, which may have important health policy implications. Until the reasons for readmission variability can be addressed, reporting the current HWR metric as an indicator of hospital quality should be reevaluated.

     

Optimal duration of antimicrobial therapy for uncomplicated Gram-negative bloodstream infections

Purpose

Optimal antimicrobial treatment duration for Gram-negative bloodstream infection (BSI) remains unclear. This retrospective cohort study examined effectiveness of short (7–10 days) and long (>10 days) courses of antimicrobial therapy for uncomplicated Gram-negative BSI.

Methods

Hospitalized adults with uncomplicated Gram-negative BSI at Palmetto Health hospitals in Columbia SC, USA from January 1, 2010 to December 31, 2013 were identified. Multivariate Cox proportional hazards regression with propensity score adjustment was used to examine risk of treatment failure in the two groups.

Results

During the study period, 117 and 294 patients received short and long courses of antimicrobial therapy for uncomplicated Gram-negative BSI, respectively. Overall, the median age was 67 years, 258 (63%) were women, 282 (69%) had urinary source of infection, and 271 (66%) had BSI due to Escherichia coli. The median duration of antimicrobial therapy was 8.5 and 13.3 days in the short and long treatment groups, respectively. After adjustment for the propensity to use a short course of therapy, risk of treatment failure was higher in patients receiving short compared to long courses of antimicrobial agents (HR 2.60, 95% CI: 1.20–5.53, p = 0.02). Other risk factors for treatment failure included liver cirrhosis (HR 5.83, 95% CI: 1.89–15.02, p = 0.004) and immune compromised status (HR 4.30, 95% CI: 1.57–10.80, p = 0.006). Definitive antimicrobial therapy with intravenous or highly bioavailable oral agents was associated with reduced risk of treatment failure (HR 0.33, 95% CI: 0.14–0.73, p = 0.006).

Conclusions

The current results support common clinical practice of 2 weeks of antimicrobial therapy for uncomplicated Gram-negative BSI.

     

Intestinal colonisation and blood stream infections due to vancomycin-resistant enterococci (VRE) and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) in patients with haematological and oncological malignancies

Background

In patients with haematological or oncological malignancies, we aimed to assess the rate of intestinal colonisation and blood stream infections (BSI) with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci (VRE), mortality and risk factors associated with ESBLE/VRE BSI, as well as the impact of faecal screening for ESBLE and VRE in combination with adapted empiric treatment of febrile neutropenia.

Methods

Within 72?h of admission to our department, an ESBLE and VRE screening stool sample was collected. In the case of neutropenic fever, blood cultures were drawn. Data of all admitted patients were prospectively documented. Explorative forward-stepwise logistic regression analyses were used to identify risk factors for progression from intestinal colonisation to BSI.

Results

During the study period, 1,805 stool samples were obtained from 513 patients during 1,012 inpatient stays, and 2,766 blood cultures were obtained from 578 patients during 1,091 inpatient stays. Ninety (17.5?%) of these patients were colonised with ESBLE and 51 (9.9?%) with VRE. Proportions of 40?% (36/90) of ESBLE and 61?% (31/51) of VRE colonisations were healthcare-associated. Six of 90 (6.6?%) ESBLE-colonised patients and 1/51 (2?%) VRE-colonised patients developed BSI with the respective organism. None of these patients died after receiving early appropriate empiric antibiotics based on colonisation status. Colonisation with ESBLE or VRE was associated with increased risk ratios (RR) towards developing ESBLE BSI [RR 4.5, 95 % confidence interval (CI): 2.89?C7.04] and VRE BSI (RR 10.2, 95 % CI: 7.87?C13.32), respectively. Acute myelogenous leukaemia and prior treatment with platinum analogues or quinolones were identified as independent risk factors for ESBLE BSI in colonised patients.

Conclusions

Intestinal ESBLE/VRE colonisation predicts BSI. Faecal screening in haematology/oncology patients in combination with directed empiric treatment may reduce ESBLE BSI-related mortality.     

Risk of death after first-time blood stream infection in incident dialysis patients with specific consideration on vascular access and comorbidity

Background

The mortality following blood stream infection (BSI) and risk of subsequent BSI in relation to dialysis modality, vascular access, and other potential risk factors has received relatively little attention. Consequently, we assessed these matters in a retrospective cohort study, by use of the Danish nation-wide registries.

Methods

Patients more than 17?years of age, who initiated dialysis between 1.1.2010 and 1.1.2014, were grouped according to their dialysis modality and vascular access. Survival was modeled in time-dependent Cox proportional hazard analyses. Potential risk factors confined by a modified Charlson comorbidity index (MCCI), were subsequently assessed in stepwise selection models.

Results

At baseline, 764 patients received peritoneal dialysis (PD), and 434, 479, and 782 hemodialysis (HD) patients were dialyzed by use of arteriovenous fistulas (AVFs), tunneled catheters (TCs), and non-tunneled catheters (NTCs), respectively. We identified 1069 BSIs with an overall incidence rate of 17.7 episodes per 100 person years, and 216 BSIs occurred more than one time in the same patient. HRs of post BSI mortality relative to PD were 3.20 (95% CI 1.86–5.50; p <?0.001) with NTCs; whereas no associations were found for AVF and TC. The risk of subsequent BSIs was higher with NTCs [HR 2.29 (95% CI 1.09–4.82), p =?0.030], and no significant difference was found for AVF and TC, in relation to PD. There was an increased risk of both outcomes with TC relative to AVF [death: 1.57 (95% CI 1.07–2.29, P <?0.021); BSI: 1.78 (95% CI 1.13–2.83, P <?0.014], and risk of death was reduced in patients who changed to AVF after first-time BSI. The MCCI was significantly associated with the risk of subsequent BSI and post BSI death; however, only some of the variables contained in the index were found to be significant risk predictors when analyzed in the fitted model.

Conclusions

While NTC was the most predominant risk factor for subsequent BSI and post BSI mortality, AVF appeared protective.

     

Does serum procalcitonin aid in the diagnosis of bloodstream infection regardless of whether patients exhibit the systemic inflammatory response syndrome?

Background

Physicians frequently rely on the systemic inflammatory response syndrome (SIRS) criteria to detect bloodstream infections (BSIs). We evaluated the diagnostic performance of procalcitonin (PCT) in detecting BSI in patients with and without SIRS.

Methods

We tested the association between BSI, serum PCT levels, contemporaneous SIRS scores and serum lactate using logistic regression in a dataset of 4279 patients. The diagnostic performance of these variables was assessed.

Results

In multivariate regression analysis, only log(PCT) was independently associated with BSI (p < 0.05). The mean area under the curve (AUC) of PCT in detecting BSI (0.683; 95% CI 0.65–0.71) was significantly higher than serum lactate (0.615; 95% CI 0.58–0.64) and the SIRS score (0.562; 95% CI 0.53–0.58). The AUC of PCT did not differ significantly by SIRS status. PCT of less than 0.1 ng/mL had a negative predictive value (NPV) of 97.4 and NPV of 96.2% for BSI in the SIRS-negative and SIRS-positive patients, respectively. A PCT of greater than 10 ng/mL had a LR of 6.22 for BSI in SIRS-negative patients. The probability of BSI increased exponentially with rising PCT levels regardless of SIRS status.

Conclusion

The performance of PCT for the diagnosis of BSI was not affected by SIRS status. Only PCT was independently associated with BSI, while the SIRS criterion and serum lactate were not. A low PCT value may be used to identify patients at a low risk for having BSI in both settings. An elevated PCT value even in a SIRS negative patient should prompt a careful search for BSI.

     

Bloodstream infections in patients with or without cancer in a large community hospital

Purpose

Cancer is associated with an increased risk of acquiring bloodstream infection (BSIs). Most knowledge on pathogens and outcome are derived from specialised cancer centres. We here sought to compare causative micro-organisms in BSIs in patients with or without cancer in a 600-bed teaching community hospital.

Methods

We analysed all positive blood cultures from adult patients between January 2005 and January 2011.

Results

A total of 4,918 episodes of BSI occurred in 2,891 patients, of whom 13.4 % had a diagnosis of cancer (85.5 % with a solid tumour). In both patient groups, Gram-positive isolates were more prevalent (58.7 and 61.4 % in patients with and without cancer, respectively) than Gram-negative isolates (31.8 and 32.3 %, respectively). Amongst Gram-positive organisms, coagulase-negative staphylococci, Staphylococcus aureus and enterococci were the most frequently isolated in both patient groups; in cancer patients, twice as many BSIs were caused by Enterococcus faecalis and E. faecium. Amongst Gram-negative organisms, Escherichia coli was the most common isolate; in cancer patients, twice as many BSIs were caused by Pseudomonas aeruginosa and Enterobacter cloacae. Yeasts were grown from 3.0 % of blood cultures from cancer patients compared to 1.5 % of cultures from non-cancer patients. Cancer patients had a 90-day mortality of 35.8 % following BSI compared to 23.5 % in patients without cancer.

Conclusion

These data demonstrate distinct BSI pathogens and impaired outcomes in patients with cancer in the setting of a large community teaching hospital.     

Association Between Staphylococcus aureus Bacteremia and Hospital Mortality in Hemodialysis Patients With Bloodstream Infection: A Multicenter Cohort From Japanese Tertiary Care Centers

Multiple studies have shown that Staphylococcus aureus bacteremia (SAB) has been a major cause of death in hemodialysis patients. We examined whether SAB is a risk for mortality among chronic hemodialysis patients in Japan where the standard vascular access is arteriovenous fistula (AVF). This was a multicenter, retrospective study of maintenance hemodialysis patients with bloodstream infection (BSI) from 2011 to 2013 at tertiary care centers in Japan. The endpoint was hospital mortality. Our cohort contained 32 SAB cases (14 MRSA and 18 MSSA) and 42 non‐SAB cases. Hospital mortality was higher among SAB cases than non‐SAB cases (46.9% vs. 23.8%, P = 0.038). In patients with BSI, SAB was significantly associated with hospital mortality after adjustment for potential confounders, including type of vascular access (OR 3.26). S. aureus was the leading cause of BSI and hospital mortality among this cohort. Therefore, initial empiric treatment should cover for S. aureus.     

Development and Validation of an Acute Heart Failure-Specific Mortality Predictive Model Based on Administrative Data

Background

Acute heart failure (AHF) with its high in-hospital mortality is an increasing burden on healthcare systems worldwide, and comparing hospital performance is required for improving hospital management efficiency. However, it is difficult to distinguish patient severity from individual hospital care effects. The aim of this study was to develop a risk adjustment model to predict in-hospital mortality for AHF using routinely available administrative data.

Methods

Administrative data were extracted from 86 acute care hospitals in Japan. We identified 8620 hospitalized patients with AHF from April 2010 to March 2011. Multivariable logistic regression analyses were conducted to analyze various patient factors that might affect mortality. Two predictive models (models 1 and 2; without and with New York Heart Association functional class, respectively) were developed and bootstrapping was used for internal validation. Expected mortality rates were then calculated for each hospital by applying model 2.

Results

The overall in-hospital mortality rate was 7.1%. Factors independently associated with higher in-hospital mortality included advanced age, New York Heart Association class, and severe respiratory failure. In contrast, comorbid hypertension, ischemic heart disease, and atrial fibrillation/flutter were found to be associated with lower in-hospital mortality. Both model 1 and model 2 demonstrated good discrimination with c-statistics of 0.76 (95% confidence interval, 0.74-0.78) and 0.80 (95% confidence interval, 0.78-0.82), respectively, and good calibration after bootstrap correction, with better results in model 2.

Conclusions

Factors identifiable from administrative data were able to accurately predict in-hospital mortality. Application of our model might facilitate risk adjustment for AHF and can contribute to hospital evaluations.     

Successful heart transplantation in patients with total artificial heart infections

Background

Data are limited on clinical outcomes in patients awaiting heart transplant (HT) with total artificial heart (TAH) infections.

Methods

We retrospectively reviewed all TAH recipients at our center. TAH infection was classified as definite if a microorganism was isolated in cultures from the exit site or deep tissues around the TAH; as probable in patients without surgical or microbiologic evidence of infection but no other explanation for persistent or recurrent bloodstream infection (BSI); or possible in patients with clinical suspicion and radiographic findings suggestive of TAH infection, but without surgical intervention or microbiologic evidence.

Results

From 2012 to 2015, a total of 13 patients received a TAH, with a median age at implantation of 52 years (range: 28‐60). TAH infection occurred in nine patients (seven definite, one probable, one possible) a median of 41 days after implant (range: 17‐475). The majority of TAH infections were caused by Staphylococcus species. Seven of nine patients underwent HT (four had pre‐HT mediastinal washout, and five had positive HT operative cultures). Three patients had an active BSI caused by the same pathogen causing TAH infection at the time of HT, with one developing a post‐HT BSI with the same bacteria. No patient developed post‐HT surgical site infection caused by the TAH infection pathogen. No deaths among HT recipients were attributed to infection.

Conclusion

TAH infection is frequently associated with BSI and mediastinitis and Staphylococcus was the most common pathogen. A multimodal approach of appropriate pre‐ and post‐HT antimicrobial therapy, surgical drainage, and heart transplantation with radical mediastinal debridement was successful in curing infection.     

Risk factors for catheter-related bloodstream infection: a prospective multicenter study in Brazilian intensive care units

IntroductionCentral venous catheters (CVC) are devices of great importance in health care. The advantages gained from the use of catheters outweigh the complications that might result from their use, among which bloodstream infections (BSI). In spite of its importance, few national studies have addressed this issue.ObjectiveThe aim this study was to determine the incidence of BSI in patients with CVC, hospitalized in ICU, as well as the variables associated with this complication.MethodsMulticentric cohort study carried out at ICUs of three hospitals at Universidade Federal de São Paulo complex.ResultsA total of 118 cases of BSI in 11.546 catheters day were observed: 10.22 BSI per 1,000 catheters day. On average, BSI was associated to seven additional days of hospital stay in our study (p < 0.001), with a significant difference between types of catheters. Concerning the place of insertion, there was no statistical difference in BSI rates.ConclusionWe concluded that a patient who uses a catheter for longer than 13 days presents a progressive risk for infection of approximately three times higher in relation to a patient who uses the catheter for less than 13 days (p < 0.001). The median duration of catheter use was 14 days among patients with BSI and 9 days in patients without infection (p < 0.001). There was higher prevalence of Gram-negative infections. The risk factors for BSI were utilization of multiple-lumen catheters, duration of catheterization and ICU length of stay.     

Effect of the Hospital Elder Life Program on Risk of 30‐Day Readmission

Objectives

To compare rates of 30‐day readmission between hospital units with a Hospital Elder Life Program (HELP) and control units without HELP.

Design

Retrospective cohort study.

Setting

The study took place from July 1, 2013, to June 30, 2014, at the University of Pittsburgh Medical Center Shadyside, a 520‐bed community teaching hospital that has used HELP since 2002. Eight medical and surgical units with HELP were compared with 10 medical and surgical units without HELP.

Participants

During the study period, HELP units, had 4,794 patients aged 70 and older, and usual care units had 2,834.

Intervention

HELP is a multifactorial, multidisciplinary program that provides targeted interventions for delirium risk factors in at‐risk individuals in collaboration with bedside staff.

Measurements

Mixed‐effects Poisson regression models were used to estimate the adjusted incident risk ratio for 30‐day readmission between HELP and usual care units for the overall cohort and for the subgroup of individuals discharged home, with or without services.

Results

Patients on HELP units were more likely than those in usual care units to be older, female, and black and had an unadjusted readmission rate of 16.9%, versus 18.9% for patients on control units. The adjusted risk of readmission was 0.83 (95% confidence interval (CI) = 0.73–0.94, P = .003) for HELP unit patients overall and 0.74 (95% CI = 0.63–0.87, P < .001) for HELP unit patients discharged to home with or without services.

Conclusion

The HELP program is associated with lower risk of 30‐day hospital readmission overall and for the subgroup of individuals discharged to home. Prospective studies are needed to confirm these observations.     

Variations in Practice Patterns and Consistency With Published Guidelines for Balloon Aortic and Pulmonary Valvuloplasty: An Analysis of Data From the IMPACT Registry

Objectives

The authors sought to study variation in the practice of balloon aortic (BAV) and pulmonary valvuloplasty (BPV).

Hospital Performance Measures and 30-day Readmission Rates

BACKGROUND

Lowering hospital readmission rates has become a primary target for the Centers for Medicare & Medicaid Services, but studies of the relationship between adherence to the recommended hospital care processes and readmission rates have provided inconsistent and inconclusive results.

OBJECTIVE

To examine the association between hospital performance on Medicare’s Hospital Compare process quality measures and 30-day readmission rates for patients with acute myocardial infarction (AMI), heart failure and pneumonia, and for those undergoing major surgery.

DESIGN, SETTING AND PARTICIPANTS

We assessed hospital performance on process measures using the 2007 Hospital Inpatient Quality Reporting Program. The process measures for each condition were aggregated in two separate measures: Overall Measure (OM) and Appropriate Care Measure (ACM) scores. Readmission rates were calculated using Medicare claims.

MAIN OUTCOME MEASURE

Risk-standardized 30-day all-cause readmission rate was calculated as the ratio of predicted to expected rate standardized by the overall mean readmission rate. We calculated predicted readmission rate using hierarchical generalized linear models and adjusting for patient-level factors.

RESULTS

Among patients aged ≥ 66 years, the median OM score ranged from 79.4 % for abdominal surgery to 95.7 % for AMI, and the median ACM scores ranged from 45.8 % for abdominal surgery to 87.9 % for AMI. We observed a statistically significant, but weak, correlation between performance scores and readmission rates for pneumonia (correlation coefficient R?=?0.07), AMI (R?=?0.10), and orthopedic surgery (R?=?0.06). The difference in the mean readmission rate between hospitals in the 1st and 4th quartiles of process measure performance was statistically significant only for AMI (0.25 percentage points) and pneumonia (0.31 percentage points). Performance on process measures explained less than 1 % of hospital-level variation in readmission rates.

CONCLUSIONS

Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates compared to those with lower levels of performance.     

Provider profiling models for acute coronary syndrome mortality using administrative data

Background

Administrative data have been used to construct risk-adjustment models for provider profiling to benchmark hospital performance for acute myocardial infarction (AMI), but much less for acute coronary syndrome (ACS). We assess the impact on risk model performance and hospital-level mortality rate ratios (SMRs) of three key issues: comorbidity measurement methods, inter-hospital transfers and post-discharge deaths.

Methods

Logistic regression models for 30-day total mortality used three years of national public hospital emergency (unplanned) admissions data for England for ACS (n = 329,369) linked to death registrations. We compared using the Charlson comorbidity index with modelling previous admissions.

Results

Prior admission for various conditions such as cancer and renal failure was associated with higher post-ACS mortality, whereas previous AMIs, PCI and unstable angina admissions were associated with lower mortality. The Charlson comorbidity index performed better than one- and five-year admission histories. Discrimination (c = 0.81) was comparable with that from clinical databases. Adjusted 30-day total mortality rates ranged between hospitals from 6.3% to 13.3%.Median differences in SMRs between the comorbidity-adjustment methods were small. Although SMRs and outlier status could change, a hospital's ‘qualitative’ mortality rating (low, average or high) was not affected. In contrast, a sizeable minority of SMRs changed by ≥ 10 points if transfers were excluded or post-discharge deaths ignored. Model choice occasionally affected funnel plot outlier status.

Conclusions

Models for comparing hospitals' ACS mortality can be constructed with good discrimination using English administrative hospital data. Adjusting for transfers in and capturing post-discharge deaths are more important than the choice of comorbidity adjustment.     

Successful heart transplantation in patients with active Staphylococcus bloodstream infection and suspected mechanical circulatory support device infection

Background

An active bloodstream infection (BSI) is typically considered a contraindication to heart transplantation (HT). However, in some patients with Staphylococcus bacteremia and mechanical circulatory support device infection, positive blood cultures may persist until removal of the infected device, and eradicating the infection prior to HT may not be possible. We report the outcomes of six patients with active Staphylococcus BSI at the time of HT.

Methods

All cases of HT performed at The Mount Sinai Hospital from 2009 through 2015 were reviewed. All patients with a mechanical circulatory support device and an active Staphylococcus BSI at the time of HT were included.

Results

Six patients with active Staphylococcus bacteremia and suspected mechanical circulatory support device infection underwent HT. All patients were bacteremic with Staphylococcus species at the time of HT. All were managed with antimicrobial therapy, radical debridement at the time of HT, and limited use of immunosuppression, and all survived until hospital discharge with no evidence of relapsed Staphylococcus infection.

Conclusion

These results suggest that some carefully selected patients with active Staphylococcus bacteremia and suspected mechanical circulatory support device infection may safely undergo HT, and that HT may effectively eliminate the underlying infection.     

Patient race and surgical outcomes after total knee arthroplasty: An analysis of a large regional database

Objective

To examine racial differences in surgical complications, mortality, and revision rates after total knee arthroplasty.

Methods

We studied patients undergoing primary total knee arthroplasty using 2001–2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications such as myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, as well as 30‐day and 1‐year overall mortality after elective total knee arthroplasty, between racial groups. We estimated Kaplan‐Meier 1‐ and 5‐year surgical revision rates, and fit multivariable Cox proportional hazards models to compare surgical revision by race, incorporating 5 years of followup. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume, and hospital teaching status.

Results

In unadjusted analyses, there were no significant differences by racial group for either overall 30‐day or in‐hospital complication rates, or 30‐day and 1‐year mortality rates. Adjusted Cox models incorporating 5 years of followup showed an increased risk of revisions for African American patients (hazard ratio [HR] 1.39, 95% confidence interval [95% CI] 1.08–1.80), younger patients (HR 2.30, 95% CI 1.96–2.69), and lower risk for female patients (HR 0.81, 95% CI 0.71–0.92).

Conclusion

In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, African American patients, younger patients, and male patients all had significantly higher rates of revision based on 5 years of followup.