Variation in Surgical Quality Measure Adherence within Hospital Referral Regions: Do Publicly Reported Surgical Quality Measures Distinguish among Hospitals That Patients Are Likely to Compare?

Objective

To determine whether surgical quality measures that Medicare publicly reports provide a basis for patients to choose a hospital from within their geographic region.

Data Source

The Department of Health and Human Services'' public reporting website, Medicare Claims Processing Manual Baltimore, MD CMS http://www.medicare.gov/hospitalcompare.

Study Design

We identified hospitals (n = 2,953) reporting adherence rates to the quality measures intended to reduce surgical site infections (Surgical Care Improvement Project, 1–3) in 2012. We defined regions within which patients were likely to compare hospitals using the hospital referral regions (HRRs) from the Dartmouth Atlas of Health Care Project. We described distributions of reported SCIP adherence within each HRR, including medians, interquartile ranges (IQRs), skewness, and outliers.

Principal Findings

Ninety-seven percent of HRRs had median SCIP-1 scores ≥95 percent. In 93 percent of HRRs, half of the hospitals in the HRR were within 5 percent of the median hospital''s score. In 62 percent of HRRs, hospitals were skewed toward the higher rates (negative skewness). Seven percent of HRRs demonstrated positive skewness. Only 1 percent had a positive outlier. SCIP-2 and SCIP-3 demonstrated similar distributions.

Conclusions

Publicly reported quality measures for surgical site infection prevention do not distinguish the majority of hospitals that patients are likely to choose from when selecting a surgical provider. More studies are needed to improve public reporting''s ability to positively impact patient decision making.     

温血心停跳液与冷晶体心停跳液对狗心率变异性的影响

为探讨体外循环（ＣＰＢ）导致心脏植物神经系统（ＣＡＳ）损伤的机理,了解温血心停跳液能否防止ＣＰＢ后心率变异性（ＨＲＶ）的降低,采用对照方法观察了温血心停跳液与冷晶体心停跳液对狗ＨＲＶ的影响。结果显示：ＣＰＢ后温血心停跳液组（ＷＢ组）和冷晶体心停跳液组（ＣＣ组）的全频谱（ＴＰ）、低频（ＬＦ）和高频（ＨＦ）均较术前明显降低（Ｐ＜０．０５）,而且ＣＣ组比ＷＢ组降低更明显（Ｐ＜０．０５）,但ＬＦ／ＨＦ在组内及组间均无明显变化（Ｐ＞０．０５）。ＣＰＢ后２４小时平均心率（ＭＨＲ）明显增加（Ｐ＜０．０５）,且ＣＣ组高于ＷＢ组（Ｐ＜０．０５）。本研究表明：采用温血心停跳液或冷晶体心停跳液的ＣＰＢ不会干扰ＣＡＳ平衡,但均能使ＨＲＶ降低,温血心停跳液不能防止ＨＲＶ损害。     

In vitro effects of the antiallergy compound, CI-949, on interleukin-1 and 2 release, and on mitogen and alloantigen responsiveness

CI-949 (5-methoxy-3-(1-methylethoxy)-1-phenyl-N-1H-tetrazol-5-yl-1H -indole- 2-carboxamide, L-arginine salt), an antiallergy compound, was found to be a weak inhibitor of IL-1 release from LPS-stimulated murine peritoneal exudate cells and human peripheral blood leukocytes, with IC50S of 186.2 and 267.9 microM, respectively. CI-949 was also a poor inhibitor of release of IL-2 from Con A-stimulated rat splenocytes (37% inhibition at 100 microM). CI-949 did produce concentration-related inhibition of the response of human lymphocytes to PHA and Con A (IC50S = 44.7 and 21.5 microM, respectively) as well as in the mixed lymphocyte reaction (MLR) (IC50 = 16.8 microM). The clinical significance of these latter findings is unknown at present.     

Inadvertent ligation of the left pulmonary artery

In five patients, aged 4 days to 20 months, the left pulmonary artery was inadvertently ligated at the time of attempted closure of the patent ductus arteriosus. The complication was recognized in these patients between 1 day and 5 years later from findings of chest radiography, two-dimensional echocardiography with spectral analysis of Doppler shifted echoes, and angiography. In three patients, the presence of asymmetric pulmonary blood flow on chest radiographs obtained after surgery initially suggested the diagnosis. In the other two patients with bronchopulmonary dysplasia, the diagnosis was made by means of two-dimensional echocardiography and Doppler spectra in one and angiography in the other. On angiograms, the left pulmonary artery distal to the ligation was visualized by delayed opacification from aortic collaterals in three patients and by means of pulmonary venous wedge injection in one. Radiographic and echocardiographic examination with Doppler spectra may permit prompt diagnosis and early correction of this complication.     

Head and neck lesions: MR-guided aspiration biopsy

Aspiration biopsy guided with computed tomography (CT) has long been a valuable tool in the evaluation of head and neck disease. The ability to obtain diagnoses without the need for surgery has had a significant effect on patient treatment. Magnetic resonance (MR) imaging is now rapidly replacing CT as the primary imaging study for many head and neck diseases. The standard stainless steel needles used for CT-guided biopsy are unsuitable for MR-guided biopsy because significant ferromagnetic artifacts obscure the underlying anatomy. A new needle has recently been designed specifically for use with MR imaging. This needle has far less magnetic susceptibility and therefore does not cause significant image distortion. The authors describe the use of this needle in MR-guided aspiration biopsy of a variety of lesions in the head and neck.     

Inhibition of interleukin-2 production and lymphocyte responsiveness by the cell activation inhibitor, CI-959.

CI-959 (5-methoxy-3-(1-methylethoxy)-N-1H-tetrazol-5-yl-benzo [b]-thiophene-2-carboxamide), an antiallergy compound, blocked release of IL-2 from Con A stimulated rat splenocytes and human lymphocytes with respective IC50s of 19.1 and 23.1 microM. Inhibition of IL-2 production required the presence of CI-959 in culture medium for the first 9 hr. CI-959 also inhibited Con A-stimulated rat and human lymphocyte proliferation with IC50s of 4.7 and 5.4 microM, respectively. Inhibition of the Con A proliferative response could not be overcome by exogenous recombinant human IL-2 (300 units/ml) in either the rat or human systems. Although potent in the human mixed lymphocyte reaction (IC50 = 3.5 microM), CI-959 was less effective in blocking the PHA response (IC50 = 43.9 microM), and had minimal effect on the release of IL-1 and TNF alpha from LPS-stimulated human monocytes. These findings suggest that CI-959 selectively inhibits some lymphocyte functions, as opposed to monocyte functions, and that among these is the production of IL-2.     

Tongue and oropharynx: findings on MR imaging

Ten healthy subjects and 44 patients with diseases of the tongue or oropharynx were studied with magnetic resonance (MR) imaging. Axial, coronal, and sagittal images with a thickness of 4 mm were obtained with a pixel size of 0.75 X 0.75 mm on a 256 matrix. Nineteen of the patients underwent computed tomography (CT). Nine of those patients later had surgery, and the specimens were obtained for organ sectioning. These three studies as well as clinical history and physical examination findings were correlated. MR imaging was equal to or better than CT in those patients having both examinations. However, neither CT nor MR allowed recognition of histologic features or detection of microscopic spread of disease. Direct coronal and sagittal imaging planes on MR imaging allowed visualization of intrinsic tongue musculature, not possible with CT; this was important in recognizing subtle tumor extension. For these reasons, MR is the imaging method of choice for studying diseases of the tongue and oropharynx.     

Effacement of the fetal cisterna magna in association with myelomeningocele

The cisterna magna is effaced in association with myelomeningocele. The authors retrospectively investigated the size of the fetal cisterna magna as a predictor of fetal myelomeningocele in 67 pregnant women (17-38 menstrual weeks) referred for prenatal sonography because of an elevated serum alpha-fetoprotein level (n = 61) or a suspicion of fetal ventriculomegaly on previously obtained sonograms (n = 6). Twenty fetuses had myelomeningocele, 14 had isolated ventriculomegaly, and 33 were normal. A normal-sized cisterna magna (range, 4-9 mm in depth) was present in all normal fetuses. In 19 of 20 fetuses with myelomeningocele, the views of the posterior fossa were adequate, and in each of these the cisterna magna was effaced (n = 18) or very small (n = 1). The cisterna magna was effaced in five of 13 (38%) fetuses with isolated ventriculomegaly in whom the posterior fossa was adequately imaged. Although effacement of the cisterna magna is a nonspecific finding, the high negative predictive value of this sign is useful during routine screening of the fetal neural axis.