Does Winning a Pay-for-Performance Bonus Improve Subsequent Quality Performance? Evidence from the Hospital Quality Incentive Demonstration

Objective

To test whether receiving a financial bonus for quality in the Premier Hospital Quality Incentive Demonstration (HQID) stimulated subsequent quality improvement.

Data

Hospital-level data on process-of-care quality from Hospital Compare for the treatment of acute myocardial infarction (AMI), heart failure, and pneumonia for 260 hospitals participating in the HQID from 2004 to 2006; receipt of quality bonuses in the first 3 years of HQID from the Premier Inc. website; and hospital characteristics from the 2005 American Hospital Association Annual Survey.

Study Design

Under the HQID, hospitals received a 1 percent bonus on Medicare payments for scoring between the 80th and 90th percentiles on a composite quality measure, and a 2 percent bonus for scoring at the 90th percentile or above. We used a regression discontinuity design to evaluate whether hospitals with quality scores just above these payment thresholds improved more in the subsequent year than hospitals with quality scores just below the thresholds. In alternative specifications, we examined samples of hospitals scoring within 3, 5, and 10 percentage point “bandwidths” of the thresholds. We used a Generalized Linear Model to estimate whether the relationship between quality and lagged quality was discontinuous at the lagged thresholds required for quality bonuses.

Principal Findings

There were no statistically significant associations between receipt of a bonus and subsequent quality performance, with the exception of the 2 percent bonus for AMI in 2006 using the 5 percentage point bandwidth (0.8 percentage point increase, p < .01), and the 1 percent bonus for pneumonia in 2005 using all bandwidths (3.7 percentage point increase using the 3 percentage point bandwidth, p < .05).

Conclusions

We found little evidence that hospitals'' receipt of quality bonuses was associated with subsequent improvement in performance. This raises questions about whether winning in pay-for-performance programs, such as Hospital Value-Based Purchasing, will lead to subsequent quality improvement.     

Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care

Objective

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

Data Sources

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004–2008).

Study Design

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

Principal Findings

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

Conclusions

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.     

Higher Incentive Payments in Medicare Advantage's Pay‐for‐Performance Program Did Not Improve Quality But Did Increase Plan Offerings

Objective

To evaluate the effects of the size of financial bonuses on quality of care and the number of plan offerings in the Medicare Advantage Quality Bonus Payment Demonstration.

Data Sources

Publicly available data from CMS from 2009 to 2014 on Medicare Advantage plan quality ratings, the counties in the service area of each plan, and the benchmarks used to construct plan payments.

Study Design

The Medicare Advantage Quality Bonus Payment Demonstration began in 2012. Under the Demonstration, all Medicare Advantage plans were eligible to receive bonus payments based on plan‐level quality scores (star ratings). In some counties, plans were eligible to receive bonus payments that were twice as large as in other counties. We used this variation in incentives to evaluate the effects of bonus size on star ratings and the number of plan offerings in the Demonstration using a differences‐in‐differences identification strategy. We used matching to create a comparison group of counties that did not receive double bonuses but had similar levels of the preintervention outcomes.

Principal Findings

Results from the difference‐in‐differences analysis suggest that the receipt of double bonuses was not associated with an increase in star ratings. In the matched sample, the receipt of double bonuses was associated with a statistically insignificant increase of +0.034 (approximately 1 percent) in the average star rating (p > .10, 95 percent CI: −0.015, 0.083). In contrast, the receipt of double bonuses was associated with an increase in the number of plans offered. In the matched sample, the receipt of double bonuses was associated with an overall increase of +0.814 plans (approximately 5.8 percent) (p < .05, 95 percent CI: 0.078, 1.549). We estimate that the double bonuses increased payments by $3.43 billion over the first 3 years of the Demonstration.

Conclusions

At great expense to Medicare, double bonuses in the Medicare Advantage Quality Bonus Payment Demonstration were not associated with improved quality but were associated with more plan offerings.     

Using Medical Claims for Policy Effectiveness Surveillance: Reimbursement and Utilization of Abdomen/Pelvis Computed Tomography Scans

Objective

To quantify changes in private insurance payments for and utilization of abdominal/pelvic computed tomography scans (CTs) after 2011 changes in CPT coding and Medicare reimbursement rates, which were designed to reduce costs stemming from misvalued procedures.

Data Sources

TruvenHealth Analytics MarketScan Commercial Claims and Encounters database.

Study Design

We used difference‐in‐differences models to compare combined CTs of the abdomen/pelvis to CTs of the abdomen or pelvis only. Our main outcomes were inflation‐adjusted log payments per procedure, daily utilization rates, and total annual payments.

Data Extraction Methods

Claims data were extracted for all abdominal/pelvic CTs performed in 2009–2011 within noncapitated, employer‐sponsored private plans.

Principal Findings

Adjusted payments per combined CTs of the abdomen/pelvis dropped by 23.8 percent (p < .0001), and their adjusted daily utilization rate accelerated by 0.36 percent (p = .034) per month after January 2011. Utilization rate of abdominal‐only or pelvic‐only CTs dropped by 5.0 percent (p < .0001). Total annual payments for combined CTs of the abdomen/pelvis decreased in 2011 despite the increased utilization.

Conclusions

Private insurance payments for combined CTs of the abdomen/pelvis declined and utilization accelerated significantly after 2011 policy changes. While growth in total annual payments was contained in 2011, it may not be sustained if 2011 utilization trends persist.     

The impact of bisphenol A and triclosan on immune parameters in the U.S. population, NHANES 2003-2006

Background

Exposure to environmental toxicants is associated with numerous disease outcomes, many of which involve underlying immune and inflammatory dysfunction.

Objectives

To address the gap between environmental exposures and immune dysfunction, we investigated the association of two endocrine-disrupting compounds (EDCs) with markers of immune function.

Methods

Using data from the 2003–2006 National Health and Nutrition Examination Survey, we compared urinary bisphenol A (BPA) and triclosan levels with serum cytomegalovirus (CMV) antibody levels and diagnosis of allergies or hay fever in U.S. adults and children ≥ 6 years of age. We used multivariate ordinary least squares linear regression models to examine the association of BPA and triclosan with CMV antibody titers, and multivariate logistic regression models to investigate the association of these chemicals with allergy or hay fever diagnosis. Statistical models were stratified by age (< 18 years and ≥ 18 years).

Results

In analyses adjusted for age, sex, race, body mass index, creatinine levels, family income, and educational attainment, in the ≥ 18-year age group, higher urinary BPA levels were associated with higher CMV antibody titers (p < 0.001). In the < 18-year age group, lower levels of BPA were associated with higher CMV antibody titers (p < 0.05). However, triclosan, but not BPA, showed a positive association with allergy or hay fever diagnosis. In the < 18-year age group, higher levels of triclosan were associated with greater odds of having been diagnosed with allergies or hay fever (p < 0.01).

Conclusions

EDCs such as BPA and triclosan may negatively affect human immune function as measured by CMV antibody levels and allergy or hay fever diagnosis, respectively, with differential consequences based on age. Additional studies should be done to investigate these findings.     

Radiation Therapy Resources and Guideline‐Concordant Radiotherapy for Early‐Stage Breast Cancer Patients in an Underserved Region

Objective

To examine the relationship between radiation therapy resources and guideline-concordant radiotherapy after breast-conserving surgery (BCS) in Kentucky.

Data Sources

The SEER registry and Area Resource File provided county-level data describing cancer care resources and socioeconomic conditions of Kentucky residents.

Study Design

The outcome variable was rate of BCS without radiotherapy in each county for 2000–2007. Eight-year weighted average rates of radiation therapy providers and hospitals per 100,000 residents were explanatory variables of interest. Exploratory spatial data analyses and spatial econometric models were estimated.

Principal Findings

Appalachian counties in Kentucky had significantly fewer radiation oncologists, hospitals with radiation therapy facilities, and surgeons per 100,000 residents than non-Appalachian counties. The likelihood of BCS without radiation was significantly higher among Appalachian compared to non-Appalachian women (42.5 percent vs. 29.0 percent, p < .001). Higher proportions of women not receiving recommended radiotherapy after BCS were clustered in Eastern Kentucky around Lexington. This geographic disparity was partially explained by significantly fewer radiation therapy facilities in Appalachian Kentucky in adjusted analyses.

Conclusions

Scarce radiation therapy resources in Appalachian Kentucky are associated with disparities in receipt of guideline-concordant radiotherapy, suggesting that policy action is needed to improve the cancer treatment infrastructure in disadvantaged mountainous areas.     

Do Early Career Indicators of Clinical Skill Predict Subsequent Career Outcomes and Practice Characteristics for General Internists?

Objective

To study relationships between clinical skill measures assessed at the beginning of general internists'' careers and their career outcomes and practice characteristics.

Data Sources

General Internist Community Tracking Study Physician Survey respondents (2000–2001, 2004–2005) linked with residency program evaluations and American Board of Internal Medicine board certification examination score records; n = 2,331.

Study Design

Cross-sectional regressions of career outcome and practice characteristic measures on board examination scores/success, residency evaluations interacted with residency type, and potential confounding variables.

Principal Findings

Failure to achieve board certification was associated with $27,206 (18 percent, p < .05) less income and 14.9 percent more minority patients relative to physicians scoring in the bottom quartile on their initial examination who eventually became certified (p < .01). Other skill measures were not associated with income. Scoring in the top rather than bottom quartile on the board certification examination was associated with 9 percent increased likelihood of reporting high career satisfaction (p < .05). Among physicians trained in community hospital residency programs, lower evaluations were associated with 14.5 percent higher share of minority patients (p < .05). Both skill measures were associated with practice type.

Conclusions

There are associations between early career skill measures and career outcomes. In addition, minority patients are more likely to be treated by physicians with lower early career clinical skills measures than nonminority patients.     

Magnetic resonance imaging in coronary artery bypass surgery--improvement of global and segmental function in patients with severely compromized left ventricular function

Objectives

In the present study, patients with severely compromized left ventricular function underwent magnetic resonance imaging (MRI) before and after coronary artery bypass grafting (CABG). Although improvement of global myocardial contractile function has been shown before, we sought to evaluate whether a functional contractile improvement may be determinable on a myocardial segmental basis after CABG surgery.

Methods

Thirty-three CABG patients with left ventricular ejection fraction (LVEF) ≤30% prospectively underwent MRI to compare pre- and postoperative functional data. At follow-up, all survivors underwent clinical assessment. In 16 patients (three patients died perioperatively, 13 could were lost to MRI follow-up because of cardiac resynchronization therapy and other reasons) postoperative MRI scanning was performed.

Results

In-hospital mortality was 9%. At 20 ± 2 months after surgery, New York Heart Association class improved from 3.0 ± 0.1 to 2.2 ± 0.2 (p < 0.01). Left ventricular end-diastolic volumes decreased significantly from 229 ± 14 mL to 189 ± 19 mL (p < 0.05). LV end-systolic volumes decreased significantly from 163 ± 13 mL to 126 ± 17 mL (p < 0.05). LVEF improved from 30 ± 2% to 36 ± 3% (p < 0.05). On a segmental basis, 42 out of 875 segments (4.8%) had normal function before surgery, at follow-up, 177 segments (20.4%) had normal regional function (p < 0.05).

Conclusions

Patients who undergo CABG surgery with severely compromized left ventricular function, postoperative MRI shows improved global and segmental cardiac function at mid-term follow-up. At the same time there is considerable clinical improvement.     

Eleusine indica L. possesses antioxidant activity and precludes carbon tetrachloride (CCl4)-mediated oxidative hepatic damage in rats

Objectives

The purpose of this study was to evaluate the ability of aqueous extract of Eleusineindica to protect against carbon tetrachloride (CCl₄)-induced hepatic injury in rats.

Methods

The antioxidant activity of E. indica was evaluated using the 1,1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging assay. The total phenolic content of E. indica was also determined. Biochemical parameters [e.g. alanine aminotransferase (ALT), aspartate aminotransferase (AST), malondialdehyde (MDA), glutathione (GSH), catalase, glutathione peroxidase, glutathione reductase, glutathione S-transferase and quinone reductase] were used to evaluate hepatic damage in animals pretreated with E. indica and intoxicated with CCl₄. CCl₄-mediated hepatic damage was also evaluated by histopathologically.

Results

E. indica extract was able to reduce the stable DPPH level in a dose-dependent manner. The half maximal inhibitory concentration (IC₅₀) value was 2350 μg/ml. Total phenolic content was found to be 14.9 ± 0.002 mg/g total phenolic expressed as gallic acid equivalent per gram of extract. Groups pretreated with E. indica showed significantly increased activity of antioxidant enzymes compared to the CCl₄-intoxicated group (p < 0.05). The increased levels of serum ALT and AST were significantly prevented by E. indica pretreatment (p < 0.05). The extent of MDA formation due to lipid peroxidation was significantly reduced (p < 0.05), and reduced GSH was significantly increased in a dose-dependently manner (p < 0.05) in the E. indica-pretreated groups as compared to the CCl₄-intoxicated group. The protective effect of E. indica was further evident through decreased histopathological alterations in the liver.

Conclusion

The results of our study indicate that the hepatoprotective effects of E. indica might be ascribable to its antioxidant and free radical scavenging property.     

Ambulatory Surgery Centers and Their Intended Effects on Outpatient Surgery

Objectives

To assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events.

Data Sources

Twenty percent national sample of Medicare beneficiaries.

Study Design

A retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups—those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission.

Principal Findings

Adjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p < .001 for test between slopes). Within these markets, procedure use at ASCs outpaced the decline observed in the hospital setting. Perioperative mortality and admission rates remained flat after ASC opening (both p > .4 for test between slopes).

Conclusions

The opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals.     

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

Objectives

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

Data Sources/Study Setting

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

Study Design/Methods

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

Principal Findings

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach''s alpha = 0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR = 1.13, p < .05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR = 1.02, p < .01) and LDL control (OR = 1.01, p < .01) among patients with diabetes, and better BP control (OR = 1.04, p < .01) among patients with hypertension.

Conclusions

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.     

The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Objective

To assess the impact of the Patient Protection and Affordable Care Act''s (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources

Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010–2011.

Study Design

We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings

Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions

The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.     

Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa

Objective

To determine participation in polio supplementary immunization activities (SIAs) in sub-Saharan Africa among users and non-users of routine immunization services and among users who were compliant or non-compliant with the routine oral poliovirus vaccine (OPV) immunization schedule.

Methods

Data were obtained from household-based surveys in non-polio-endemic sub-Saharan African countries. Routine immunization service users were children (aged < 5 years) who had ever had a health card containing their vaccination history; non-users were children who had never had a health card. Users were considered compliant with the OPV routine immunization schedule if, by the SIA date, their health card reflected receipt of required OPV doses. Logistic regression measured associations between SIA participation and use of both routine immunization services and compliance with routine OPV among users.

Findings

Data from 21 SIAs conducted between 1999 and 2010 in 15 different countries met inclusion criteria. Overall SIA participation ranged from 70.2% to 96.1%. It was consistently lower among infants than among children aged 1–4 years. In adjusted analyses, participation among routine immunization services users was > 85% in 12 SIAs but non-user participation was > 85% in only 5 SIAs. In 18 SIAs, participation was greater among users (P < 0.01 in 16, 0.05 in 1 and < 0.10 in 1) than non-users. In 14 SIAs, adjusted analyses revealed lower participation among non-compliant users than among compliant users (P < 0.01 in 10, < 0.05 in 2 and < 0.10 in 2).

Conclusion

Large percentages of children participated in SIAs. Prior use of routine immunization services and compliance with the routine OPV schedule showed a strong positive association with SIA participation.     

Examining the Association between Utilization Management and Downstream Cardiovascular Imaging

Objectives

To examine the association of echocardiography utilization management (EUM) program with downstream cardiac imaging utilization.

Data Sources/Study Setting

Administrative claims data from commercial health plans in Indiana, Ohio, Kentucky, Wisconsin, and Georgia.

Study Design

Patients undergoing index cardiovascular imaging with no imaging in the preceding year were identified (N = 112,308). Claims-derived cardiac risk scores were used for one-to-one propensity score matching of patients subject to EUM to patients without EUM (n = 96,906). Downstream cardiac imaging utilization for 12–24 months postindex imaging was analyzed using generalized linear models and Cox proportional hazards model.

Principal Findings

Downstream cardiac imaging tests were performed for 10,630 (21.9 percent) and 12,012 (24.8 percent) patients in the EUM and non-EUM groups, respectively. At 12-month follow-up, adjusted utilization was 15.2 (95 percent CI, 7.6–22.5) tests per 1,000 initially tested patients lower in the EUM group (p < .001). The likelihood of obtaining downstream cardiac imaging in the EUM group was 7.0 percent lower than the non-EUM group (hazard ratio: 0.930; 95 percent CI, 0.897–0.964, p < .001).

Conclusions

Downstream cardiac imaging is relatively common among commercially insured patients. Every 10 initial diagnostic tests yielded two downstream imaging tests in first 24 months. EUM program was associated with lower volumes of downstream imaging.     

Reporting of Quality Indicators and Improvement in Hospital Performance: The P.Re.Val.E. Regional Outcome Evaluation Program

Objective

To evaluate whether reporting of hospital performance was associated with a change in quality indicators in Italian hospitals.

Data Sources/Study Setting

Nationwide Hospital Information System for 2006–2009.

Study Design

We performed a pre-post evaluation in Lazio (before and after disclosure of the Regional Outcome Evaluation Program P.Re.Val.E.) and a comparative evaluation versus Italian regions without comparable programs. We analyzed risk-adjusted proportions of percutaneous coronary intervention (PCI), hip fractures operated on within 48 hours, and cesarean deliveries.

Data Collection/Extraction Methods

Using standardized ICD-9-CM coding algorithms, we selected 381,053 acute myocardial infarction patients, 250,712 hip fractures, and 1,736,970 women who had given birth.

Principal Findings

In Lazio PCI within 48 hours changed from 22.49 to 29.43 percent following reporting of the P.Re.Val.E results (relative increase, 31 percent; p < .001). In the other regions this proportion increased from 22.48 to 27.09 percent during the same time period (relative increase, 21 percent; p < .001). Hip fractures operated on within 48 hours increased from 11.73 to 15.78 percent (relative increase, 34 percent; p < .001) in Lazio, and not in other regions (29.36 to 28.57 percent). Cesarean deliveries did not decrease in Lazio (34.57–35.30 percent), and only slightly decreased in the other regions (30.49–28.11 percent).

Conclusions

Reporting of performance data may have a positive but limited impact on quality improvement. The evaluation of quality indicators remains paramount for public accountability.     

Effectiveness of diet versus exercise intervention on weight reduction in local Japanese residents

Objective

To evaluate the effect of diet versus exercise intervention on weight reduction.

Methods

Participants were randomly divided by gender, age, and living area into four groups: group DE (diet and exercise, n = 16), group D (diet only, n = 15), group E (exercise only, n = 15), and group C (control, n = 16). This study ultimately aimed to help participants reduce their body mass index (BMI) by 7% of baseline value. Subjects were 62 residents (men and women ranging in age from 40 to 69 years) of two residential areas in Nara Prefecture, Japan, who participated in annual health checkups in 2006. BMI of the participants was ≥24 and <28 kg/m² at baseline examination. All participants agreed to undergo a 6-month intervention between January 2007 and September 2007.

Results

In our intention-to-treat analysis, mean change in BMI from baseline to final examination was as follows: group DE mean BMI decreased 6.6%, group D mean BMI decreased 5.3%, group E mean BMI decreased 2.3%, and group C mean BMI decreased 2.2%. The reduction in BMI from baseline to final examination was significant in all groups (DE, p < 0.001; D, p < 0.001; E, p = 0.009; C, p = 0.019). Further, mean abdominal circumference was significantly reduced in all groups. Blood glucose levels were significantly reduced only in group DE (p = 0.047).

Conclusion

Combined intervention with diet and exercise proved to be effective in weight reduction, whereas exercise intervention alone was not found to be effective.     

Untreated maternal syphilis and adverse outcomes of pregnancy: a?systematic review and meta-analysis

Objective

To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis.

Methods

PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for Treponema pallidum infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses.

Findings

Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0–74.1]; I² = 91.8%; P < 0.001) and women without syphilis (14.3% [95% CI: 11.8–17.2]; I² = 95.9%; P < 0.001).

Conclusion

Untreated maternal syphilis is associated with adverse pregnancy outcomes. These findings can inform policy decisions on resource allocation for the detection of syphilis and its timely treatment in pregnant women.     

Changes in retinol-binding protein concentrations and thyroid homeostasis with nonoccupational exposure to DDT

Background

The insecticide dichlorodiphenyltrichloroethane (DDT) has been used for malaria vector control in the northern and eastern parts of the Vhembe District of Limpopo Province, South Africa, since 1945. Bioaccumulation of DDT raises concern because it reportedly affects thyroid function.

Objective

Our objective was to investigate the association between DDT uptake (as reflected in plasma concentrations) and thyroid homeostasis while considering related factors.

Methods

We compared dietary intake, serum retinol-binding protein (RBP), transthyretin (TTR) and albumin concentrations, and liver and thyroid function between cases with evidence of a body burden of DDT in the circulation (concentration of any DDT isomer ≥ 0.02 μg/g lipid; n = 278) and controls (concentration of all DDT isomers < 0.02 μg/g lipid; n = 40) in a cross-sectional study. Further analyses were performed to assess the relevance of changes in RBP status associated with DDT uptake.

Results

RBP concentrations below the reference range were more prevalent in cases (54% vs. 10% in controls; χ² = 27.4; p < 0.001), which could not be explained by nutrient intake. We observed significantly lower thyroid hormone concentrations among cases (p ≤ 0.01). We also observed a significant linear trend for serum concentrations of free thyroxine and free triiodothyronine (p < 0.001) and a significant quadratic trend for serum thyroid-stimulating hormone (p = 0.025) and TTR (p < 0.001) across the control group and case groups with normal and relatively low RBP concentrations. Relatively low RBP concentrations were associated with significantly higher DDT and 1,1-dichloro-2,2-bis(p-chlorophenyl) ethylene (DDE) isomer concentrations and with a higher DDE/DDT ratio (p ≤ 0.01), which signifies long-term exposure. Inadequate intake of vitamin A and zinc were observed in 84% and 58%, respectively, of the total study population.

Conclusion

RBP concentrations appear to decrease in the presence of long-term DDT uptake, which may have deleterious effects on thyroid function and vitamin A nutritional status. This is of major concern in a population with poor vitamin A and zinc intake.     

An evaluation of hospital discharge records as a tool for serious work related injury surveillance

Objectives

To identify and describe work related serious injuries among sawmill workers in British Columbia, Canada using hospital discharge records, and compare the agreement and capturing patterns of the work related indicators available in the hospital discharge records.

Methods

Hospital discharge records were extracted from 1989 to 1998 for a cohort of sawmill workers. Work related injuries were identified from these records using International Classification of Disease (ICD‐9) external cause of injury codes, which have a fifth digit, and sometimes a fourth digit, indicating place of occurrence, and the responsibility of payment schedule, which identifies workers'' compensation as being responsible for payment.

Results

The most frequent causes of work related hospitalisations were falls, machinery related, overexertion, struck against, cutting or piercing, and struck by falling objects. Almost all cases of machinery related, struck by falling object, and caught in or between injuries were found to be work related. Overall, there was good agreement between the two indicators (ICD‐9 code and payment schedule) for identifying work relatedness of injury hospitalisations (kappa = 0.75, p < 0.01). There was better concordance between them for injuries, such as struck against, drowning/suffocation/foreign body, fire/flame/natural/environmental, and explosions/firearms/hot substance/electric current/radiation, and poor concordance for injuries, such as machinery related, struck by falling object, overexertion, cutting or piercing, and caught in or between.

Conclusions

Hospital discharge records are collected for administrative reasons, and thus are readily available. Depending on the coding reliability and validity, hospital discharge records represent an alternative and independent source of information for serious work related injuries. The study findings support the use of hospital discharge records as a potential surveillance system for such injuries.     

The Relationship between Patients' Perception of Care and Measures of Hospital Quality and Safety

Background

The extent to which patient experiences with hospital care are related to other measures of hospital quality and safety is unknown.

Methods

We examined the relationship between Hospital Consumer Assessment of Healthcare Providers and Systems scores and technical measures of quality and safety using service-line specific data in 927 hospitals. We used data from the Hospital Quality Alliance to assess technical performance in medical and surgical processes of care and calculated Patient Safety Indicators to measure medical and surgical complication rates.

Results

The overall rating of the hospital and willingness to recommend the hospital had strong relationships with technical performance in all medical conditions and surgical care (correlation coefficients ranging from 0.15 to 0.63; p<.05 for all). Better patient experiences for each measure domain were associated with lower decubitus ulcer rates (correlations −0.17 to −0.35; p<.05 for all), and for at least some domains with each of the other assessed complications, such as infections due to medical care.

Conclusions

Patient experiences of care were related to measures of technical quality of care, supporting their validity as summary measures of hospital quality. Further study may elucidate implications of these relationships for improving hospital care.