To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in pati... more To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1 Ï 0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR Ï 0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.
OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online sim... more OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants. METHODS: We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups. RESULTS: 107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%, P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs ...
The aim of this study was to determine the impact of all-cause inpatient harms on hospital financ... more The aim of this study was to determine the impact of all-cause inpatient harms on hospital finances and patient clinical outcomes. Research Design: A retrospective analysis of inpatient harm from 24 hospitals in a large multistate health system was conducted during 2009 to 2012 using the Institute of Healthcare Improvement Global Trigger Tool for Measuring Adverse Events. Inpatient harms were detected and categorized into harm (F-I), temporary harm (E), and no harm. Results: Of the 21,007 inpatients in this study, 15,610 (74.3%) experienced no harm, 2818 (13.4%) experienced temporary harm, and 2579 (12.3%) experienced harm. A patient with harm was estimated to have higher total cost
To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in pati... more To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1 Ï 0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR Ï 0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.
Thank you for the opportunity to revise our manuscript on nesiritide. Per the reviewers' suggesti... more Thank you for the opportunity to revise our manuscript on nesiritide. Per the reviewers' suggestions, we have changed the title of our paper to reflect a neutral tone, and we have also made significant changes to the discussion section in order to have a more balanced presentation. We have also deleted any reference to the controversial MEDai severity measure. We now rely on traditional methods and parameters such as the APR-DRG measures. The number of tables has been reduced from 5 to 4 and the word count has decreased (2753 to 2330). In addition, the paper now complies with the journal's formatting guidelines. Thank you for your attention.
In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite m... more In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite measure to lessen the reporting burden of patient harm. Before this report, two patient safety organizations had developed an electronic all-cause harm measurement system leveraging data from the electronic health record, which identified and grouped harms into five broad categories and consolidated them into one all-cause harm outcome measure. The objective of this study was to examine the relationship between this all-cause harm patient safety measure and the following three performance measures important to overall hospital safety performance: safety culture, employee engagement, and patient experience. We studied the relationship between all-cause harm and three performance measures on eight inpatient care units at one hospital for 7 months. The findings demonstrated strong correlations between an all-cause harm measure and patient safety culture, employee engagement, and patient expe...
Background: Nesiritide is indicated in the treatment of acute decompensated heart failure. Howeve... more Background: Nesiritide is indicated in the treatment of acute decompensated heart failure. However, a recent meta-analysis reported that nesiritide may be associated with an increased risk of death. Our goal was to evaluate the impact of nesiritide treatment on four outcomes among adults hospitalized for congestive heart failure (CHF) during a three-year period. Methods: CHF patients discharged between 1/1/2002 and 12/31/2004 from the Adventist Health System, a national, not-for-profit hospital system, were identified. 25,330 records were included in this retrospective study. Nesiritide odds ratios (OR) were adjusted for various factors including nine medications and/or an APR-DRG severity score. Results: Initially, treatment with nesiritide was found to be associated with a 59% higher odds of hospital mortality (Unadjusted OR = 1.59, 95% confidence interval [CI]: 1.31-1.93). Adjusting for race, low economic status, APR-DRG severity of illness score, and the receipt of nine medications yielded a nonsignificant nesiritide OR of 1.07 for hospital death (95% CI: 0.85-1.35). Nesiritide was positively associated with the odds of prolonged length of stay (all adjusted ORs = 1.66) and elevated pharmacy cost (all adjusted ORs > 5). Conclusion: In this observational study, nesiritide therapy was associated with increased length of stay and pharmacy cost, but not hospital mortality. Randomized trials are urgently needed to better define the efficacy, if any, of nesiritide in the treatment of decompensated heart failure.
CONTEXT: Respiratory symptoms have emerged as the most common physical sequel in 9/11 first respo... more CONTEXT: Respiratory symptoms have emerged as the most common physical sequel in 9/11 first responders. We assessed evolution of those symptoms over eighteen months in New York Police Officers (Hypos). METHODS: Initial survey (IS) in October 2001 included 1587 Hypos. 575 (36%) agreed to answer the follow-up survey (FUS) eighteen months later. NYPOs 9/11 exposure categories were: light (n Z 69), moderate (n Z 174) and high (n Z 228) [category was not assigned in 70 participants]. RESULTS: Respondents were 38.9 G 6.9 years old, 83.4% were males. They did not differ from nonrespondents by age, height or weight. Cough was the most common symptom reported by 43.5% and 43.5% of all officers at IS and FUS (p Z 0.7), respectively. Occurrence within exposure groups in the order of severity was 24.6%, 42.5%, and 50% (p ! 0.0001) on IS; and 30.9%, 43.7%, and 47.1% (p Z 0.059) on FUS. Wheezing was reported by 13.1% and 25.9% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 3%, 14.6%, and 15% (p Z 0.02) on IS, while increasing to 14.5%, 25.9%, and 29.4% (p Z 0.05) on FUS. Phlegm was reported by 14.4% and 67% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 1.5%, 13.8%, and 18.9% (p Z 0.001) on IS; and 21%, 35.3%, and 30.2% (p Z 0.1) on FUS. Shortness of breath (SOB) was reported by 18.9% and 43.6% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 10.1%, 13.8%, and 25.4% (p Z 0.002) on IS and 31.9%, 45.1%, and 46% (p Z 0.1) on FUS. Analysis against risk factors showed that none of the symptoms at eighteen months could be attributed to smoking, and only SOB reported at IS was modified by the use of respiratory protection. CONCLUSIONS: While cough remained the most common and stable respiratory symptom, there was a significant increase in phlegm, wheezing and shortness of breath. This observation raises concern that respiratory injury may have progressed over time and requires further monitoring.
To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in pati... more To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1 Ï 0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR Ï 0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.
OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online sim... more OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants. METHODS: We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups. RESULTS: 107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%, P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs ...
The aim of this study was to determine the impact of all-cause inpatient harms on hospital financ... more The aim of this study was to determine the impact of all-cause inpatient harms on hospital finances and patient clinical outcomes. Research Design: A retrospective analysis of inpatient harm from 24 hospitals in a large multistate health system was conducted during 2009 to 2012 using the Institute of Healthcare Improvement Global Trigger Tool for Measuring Adverse Events. Inpatient harms were detected and categorized into harm (F-I), temporary harm (E), and no harm. Results: Of the 21,007 inpatients in this study, 15,610 (74.3%) experienced no harm, 2818 (13.4%) experienced temporary harm, and 2579 (12.3%) experienced harm. A patient with harm was estimated to have higher total cost
To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in pati... more To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1 Ï 0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR Ï 0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.
Thank you for the opportunity to revise our manuscript on nesiritide. Per the reviewers' suggesti... more Thank you for the opportunity to revise our manuscript on nesiritide. Per the reviewers' suggestions, we have changed the title of our paper to reflect a neutral tone, and we have also made significant changes to the discussion section in order to have a more balanced presentation. We have also deleted any reference to the controversial MEDai severity measure. We now rely on traditional methods and parameters such as the APR-DRG measures. The number of tables has been reduced from 5 to 4 and the word count has decreased (2753 to 2330). In addition, the paper now complies with the journal's formatting guidelines. Thank you for your attention.
In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite m... more In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite measure to lessen the reporting burden of patient harm. Before this report, two patient safety organizations had developed an electronic all-cause harm measurement system leveraging data from the electronic health record, which identified and grouped harms into five broad categories and consolidated them into one all-cause harm outcome measure. The objective of this study was to examine the relationship between this all-cause harm patient safety measure and the following three performance measures important to overall hospital safety performance: safety culture, employee engagement, and patient experience. We studied the relationship between all-cause harm and three performance measures on eight inpatient care units at one hospital for 7 months. The findings demonstrated strong correlations between an all-cause harm measure and patient safety culture, employee engagement, and patient expe...
Background: Nesiritide is indicated in the treatment of acute decompensated heart failure. Howeve... more Background: Nesiritide is indicated in the treatment of acute decompensated heart failure. However, a recent meta-analysis reported that nesiritide may be associated with an increased risk of death. Our goal was to evaluate the impact of nesiritide treatment on four outcomes among adults hospitalized for congestive heart failure (CHF) during a three-year period. Methods: CHF patients discharged between 1/1/2002 and 12/31/2004 from the Adventist Health System, a national, not-for-profit hospital system, were identified. 25,330 records were included in this retrospective study. Nesiritide odds ratios (OR) were adjusted for various factors including nine medications and/or an APR-DRG severity score. Results: Initially, treatment with nesiritide was found to be associated with a 59% higher odds of hospital mortality (Unadjusted OR = 1.59, 95% confidence interval [CI]: 1.31-1.93). Adjusting for race, low economic status, APR-DRG severity of illness score, and the receipt of nine medications yielded a nonsignificant nesiritide OR of 1.07 for hospital death (95% CI: 0.85-1.35). Nesiritide was positively associated with the odds of prolonged length of stay (all adjusted ORs = 1.66) and elevated pharmacy cost (all adjusted ORs > 5). Conclusion: In this observational study, nesiritide therapy was associated with increased length of stay and pharmacy cost, but not hospital mortality. Randomized trials are urgently needed to better define the efficacy, if any, of nesiritide in the treatment of decompensated heart failure.
CONTEXT: Respiratory symptoms have emerged as the most common physical sequel in 9/11 first respo... more CONTEXT: Respiratory symptoms have emerged as the most common physical sequel in 9/11 first responders. We assessed evolution of those symptoms over eighteen months in New York Police Officers (Hypos). METHODS: Initial survey (IS) in October 2001 included 1587 Hypos. 575 (36%) agreed to answer the follow-up survey (FUS) eighteen months later. NYPOs 9/11 exposure categories were: light (n Z 69), moderate (n Z 174) and high (n Z 228) [category was not assigned in 70 participants]. RESULTS: Respondents were 38.9 G 6.9 years old, 83.4% were males. They did not differ from nonrespondents by age, height or weight. Cough was the most common symptom reported by 43.5% and 43.5% of all officers at IS and FUS (p Z 0.7), respectively. Occurrence within exposure groups in the order of severity was 24.6%, 42.5%, and 50% (p ! 0.0001) on IS; and 30.9%, 43.7%, and 47.1% (p Z 0.059) on FUS. Wheezing was reported by 13.1% and 25.9% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 3%, 14.6%, and 15% (p Z 0.02) on IS, while increasing to 14.5%, 25.9%, and 29.4% (p Z 0.05) on FUS. Phlegm was reported by 14.4% and 67% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 1.5%, 13.8%, and 18.9% (p Z 0.001) on IS; and 21%, 35.3%, and 30.2% (p Z 0.1) on FUS. Shortness of breath (SOB) was reported by 18.9% and 43.6% on IS and FUS (p ! 0.0001), respectively. Its frequency in exposure brackets was 10.1%, 13.8%, and 25.4% (p Z 0.002) on IS and 31.9%, 45.1%, and 46% (p Z 0.1) on FUS. Analysis against risk factors showed that none of the symptoms at eighteen months could be attributed to smoking, and only SOB reported at IS was modified by the use of respiratory protection. CONCLUSIONS: While cough remained the most common and stable respiratory symptom, there was a significant increase in phlegm, wheezing and shortness of breath. This observation raises concern that respiratory injury may have progressed over time and requires further monitoring.
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