Background: During the evaluation of a donor candidate for living kidney donation, occasionally a concomitant benign abdominal disease is diagnosed. Combining organ donation and surgical treatment of that disease could be beneficial to the donor. This paper quantified the additional risk to the donor if the two operations were combined. Study design: The clinical database of 155 academic medical centers and affiliated hospitals of University HealthSystem Consortium was used to predict the minimum expected surgical risk of a combined laparoscopic cholecystectomy and laparoscopic donor nephrectomy. Results: Our model predicted that a minimum of 8.64% of patients undergoing laparoscopic cholecystectomy at the same time as a donor nephrectomy would experience at least one complication. This represents an increase of 2.3% (relative risk=1.24) from the 6.34% risk for patients undergoing only the cholecystectomy. Conclusion: The estimation of increased risk is a necessary step to obtain informed consent from a donor offered or who wants to undergo multiple procedures simultaneously.

BACKGROUND AND OBJECTIVES:Over the past 10--15 years, the number of hospitalists has grown from a few hundred to over 30,000, and hospitalists have assumed a greater proportion of the care of hospitalized patients. No existing studies report on the impact this movement has had on the characteristics of the hospital practice of family physicians in teaching hospitals. To explore this impact we examined the volume and scope of discharges by family physicians at teaching hospitals in 2003 and 2012, the most recent decade of hospitalist growth. We also compared the characteristics of family physicians' hospital practices in 2012 with hospitalists in 2012 to assess for differences in hospital performance.METHODS:We used the University Health Consortium (UHC) Clinical Database to capture adult non-pregnancy-related inpatient discharges in US teaching hospitals by family physicians and hospitalists in 2003 and 2012. We calculated the proportion of inpatient discharges by specialty in all UCH hospitals; did a qualitative comparison of frequent discharge diagnoses; and analyzed length of stay, case mix index, 7- and 30-day readmission rates, and mortality by specialty using UHCs risk adjustment methodology.RESULTS:The proportion of all inpatient discharges by family physicians in UHC hospitals was stable between 2003 and 2012 (2.7% versus 2.6%) though the volume increased. Over the same time, the proportion of discharges attributable to hospitalists increased (0.0% to 13.9%) with a concomitant decrease in proportion of discharges from general medicine (18.4% to 13.9%) and all other specialties (78.9% to 73.2%). Fourteen of the top 20 discharge diagnoses by family physicians from UHC hospitals were the same between 2003 and 2012. Family physicians and hospitalists shared 17 of the top 20 discharge diagnoses in 2012. Length of hospital stay was stable for family medicine across time and lower than that of hospitalists (4.5 versus 5.5 days; P<.001). Seven- and 30-day readmission rates for any cause were lower for hospitalists but there was no difference in either rate when limited to readmission for the same DRG. Hospitalists cared for a somewhat more complex patient mix.CONCLUSIONS:The growth of hospitalists has had little to no impact on the proportion of inpatient discharges in teaching hospitals by family physicians. Quality of care as judged by length of stay, mortality, and readmission rates was comparable between family physicians and hospitals in 2012.

BACKGROUND:Hospital-acquired venous thromboembolism (HA-VTE, VTE occurring during a hospitalization) codes in hospital billing data are often used as a surrogate for hospital-associated VTE events occurring during or up to 30 days after a hospitalization, which are more difficult to measure.OBJECTIVE:Establish the incidence and composition of HA-VTE/superficial venous thrombosis (SVT) coded in a large cohort of medical patients.DESIGN:Retrospective analysis of discharges.SETTING:Eighty-three academic medical centers in UHC (formerly University HealthSystem Consortium).PATIENTS:Patients with medical diagnoses hospitalized >2 days between October 1, 2009, and March 31, 2011.MEASUREMENTS:Incidence and anatomic location of HA-VTE codes, defined as International Classification of Diseases, Ninth Revision, Clinical Modification codes for VTE coupled to a present-on-admission indicator flag set to "No."RESULTS:Among 2,525,068 medical hospitalizations, 12,847 (0.51%) cases had ≥1 thrombotic code; 2449 (19.1%) with pulmonary embolism (PE), and 3848 (30%) with lower-extremity deep venous thrombosis (LE-DVT) without PE. Upper-extremity DVT (2893; 22.5%) and SVT (3248; 25.3%) comprised the bulk of remaining cases. Among cases with HA-PE/LE-DVT, 34.3% had cancer, 47.8% received care in an intensive care unit, 78% had severe or extreme severity of illness, and 16.5% died in the hospital. Overall, 54.9% of the patients who developed a HA-PE/LE-DVT had been started on VTE pharmacoprophylaxis on hospital day 1 or 2.CONCLUSION:At academic centers, HA-VTE/SVT is coded in 0.51% of medical inpatients, and HA-PE/LE-DVT is coded in half of those. Most patients with HA-PE/LE-DVT are severely ill and develop VTE despite receiving prophylaxis.

BACKGROUND: Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly among institutions. This variability has the potential to be reflected in the resources expended providing care. In various healthcare environments, increased resource expenditure has been associated with a favorable effect on outcome. OBJECTIVE: To examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy. METHODS: We developed analytic models employing the University Health Systems Consortium (Oakbrook, Illinois) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, post-discharge destination, and survival. Mean resource intensity of participating academic medical centers was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach that incorporated patient-level demographic and clinical variables and institution-level resource intensity. RESULTS: We analyzed data from 44,124 ARF subjects, 4,776 (10.8%) of whom underwent tracheostomy. Compared to low-resource-intensity settings, treatment in high-resource-intensity academic medical centers was associated with increased risk of mortality (odds ratio 1.11, 95% CI 1.05–1.76), including those managed with tracheostomy (odds ratio high-resource-intensity academic medical center with tracheostomy 1.10, 95% CI 1.04–1.17). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (P > .05 for both), mortality for tracheostomy patients experiencing complications was greater in high-resource-intensity (95/313, 30.3%) versus low-resource-intensity (552/2,587, 21.3%) academic medical centers (P < .001). CONCLUSIONS: We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy.

Background: Hepatocellular carcinoma (HCC) is a growing worldwide problem.Our aim is to track changes in hospitalization rates, mean hospital procedure volume, treatment options, age of treated patients, and procedure-related inpatient mortality over the last decade.Methods: University Health Consortium is a nationwide clinical and administrative database of all payers' discharge records compiled from 90% of non-profit academic medical centers in the U.S. Adult admissions with a primary discharge diagnosis of HCC between 2003-2010 were identified using International Disease Codes 9th edition.Information about age, inpatient death, treatment type [liver transplant, resection, ablation, transarterial chemoembolization (TACE)] was extracted.Trends over time were analyzed using the Jointpoint Regression Program, Version 3.5.2(October 2011, Statistical Research and Applications Branch, National Cancer Institute) and were reported as the Average Annual Percentage Change (AAPC) with corresponding 95% confidence intervals.Results: We identified 27,244 HCC patients had 30,814 admissions in which 15,571 treatment procedures were performed.Rates of (HCC admission/all causes admission), yearly mean hospital procedure volume for transplant and resection increased: AACP 0.9% (0.1,1.6), 1.9% (-1.5,5.4) and 7.2% (4.7,9.8)respectively.In contrast, yearly mean hospital procedure volume decreased for ablation -1.3% (-4.1,1.6) and was unchanged for TACE -0.4% ( -4.8,4.2).Close pattern was observed in the rates of specific treatment options per HCC patient per year, increased for transplant and resection 1.2% (-1.7,4.1),3.6% (2.1,5.3)respectively, decreased for ablation and TACE -4.4% (-7.5,-1.1),-1.4% (-4.2,1.4)respectively (Figure 1).Mean age for patients receiving transplants and resection increased AAPC 0.6% (0.1,1.1), 0.5% (0.3,0.6) respectively, while staying unchanged for ablation and TACE 0.1% (-0.3,0.5),0.1% (-0.4,0.6)respectively.The trend for procedure-related inpatient mortality decreased for transplant, resection and TACE: -4.4% (-14.4,6.8),-7.1% (-13.9,0.2) and -10.3% (-16.2,-4)respectively.While, mortality did not change for ablation 0.1% (-16.1,19.4).Conclusion: (1) HCC admissions rate and hospital procedure volumes increased significantly.(2)There has been a shift towards more transplant and resection as well as (3) decreased inpatient mortality and increased mean age at treatment.This shift in treatment allocation for HCC maybe explained by surveillance and early detection programs.

Background: The incidence and mortality of Colorectal Cancer (CRC) is higher in African Americans (AA) compared to Whites, thought to be largely due to lower adherence to screening in AA.CRC screening guidelines recommend colonoscopy or annual gFOBT as screening options.However, adherence is essential to the effectiveness of either modality.We previously reported equivalent adherence to screening colonoscopy in AA (78%) and Whites (83%) with equal access and navigation.We now present data on adherence to a program of annual gFOBT in AA compared to Whites in the same randomized controlled trial.Methods: The NCS is a randomized controlled trial of Screening Colonoscopy versus a program of annual gFOBT testing with a sensitive slide (Hemoccult SENSA) and gFOBT directed colonoscopy involving 3 clinical centers (University of Minnesota, Minneapolis;

Rationale: The National Quality Forum recently endorsed in-hospital mortality and intensive care unit length of stay (LOS) as quality indicators for patients in the intensive care unit. These measures may be affected by transferring patients to long-term acute care hospitals (LTACs).Objectives: To quantify the implications of LTAC transfer practices on variation in mortality index and LOS index for patients in academic medical centers.Methods: We used a cross-sectional study design using data reported to the University HealthSystem Consortium from 2008-2009. Data were from patients who were mechanically ventilated for more than 96 hours.Measurements and Main Results: Using linear regression, we measured the association between mortality index and LTAC transfer rate, with the hospital as the unit of analysis. Similar analyses were conducted for LOS index and cost index. A total of 137 hospitals were analyzed, averaging 534 transfers to LTAC per hospital during the study period. Mean +/- SD in-hospital mortality was 24 +/- 6.4%, and observed LOS was 30.4 +/- 8.2 days. The mean LTAC transfer rate was 15.7 +/- 13.7%. Linear regression demonstrated a significant correlation between transfer rate and mortality index (R(2) = 0.14; P < 0.0001) and LOS index (R(2) = 0.43; P < 0.0001).Conclusions: LTAC hospital transfer rate has a significant impact on reported mortality and LOS indices for patients requiring prolonged acute mechanical ventilation. This is an example of factors unrelated to quality of medical care or illness severity that must be considered when interpreting mortality and LOS as quality indicators.

BACKGROUND:Proton pump inhibitors have numerous important side effects, yet they are prescribed for outpatients who do not have recognized indications. Less is known with respect to prescribing for inpatients.OBJECTIVE:To determine the rate of inappropriate prescribing of protein pump inhibitors and to assess reasons why they are prescribed.DESIGN AND PARTICIPANTS:The study was a retrospective review of administrative data for adult hospital patients discharged from the Medicine service of Denver Health (DH) and from the University HealthSystem Consortium (UHC) between January 1, 2008 and December 31, 2009.MEASUREMENTS:Valid indications for proton pump inhibitors were sought from discharge diagnoses, prescription records, and, in a randomly selected group of patients from DH, from direct review of records.RESULTS:Inclusion criteria were met by 9875 DH patients and 6,592,100 UHC patients; of patients receiving a proton pump inhibitor, 61% and 73%, respectively, did not have a valid indication. Increased rates of Clostridium difficile infection were found in both groups of patients receiving proton pump inhibitors. Chart reviews found valid indications for proton pump inhibitors in 19% of patients who did not have a valid indication on the basis of the administrative data, and "prophylaxis" was the justification for inappropriate prescribing in 56%.CONCLUSION:Proton pump inhibitors are frequently inappropriately prescribed to Medicine inpatients who do not have a valid indication and this practice is associated with an increase in C. difficile infection. Interventions are needed to curtail this inappropriate prescribing practice.

OBJECTIVE:Describe data from patients undergoing outpatient thyroid surgeries for benign and malignant disease at academic medical centers in the United States.STUDY DESIGN:Retrospective database search.SETTING:The University Health System Consortium (UHC), Oak Brook, Illinois, data compiled from discharge summaries.SUBJECTS AND METHODS:Discharge data were collected from the first quarter of 2005 through the fourth quarter of 2010. Searching strategy was based on diagnosis of thyroid disease and patients undergoing thyroid surgery across all UHC facilities. Demographic information was collected as well as charges. Complications were also evaluated in this analysis.RESULTS:During the study period, 38,362 outpatient thyroidectomies were performed from our sample, 32% for thyroid cancer. More total thyroidectomies (43%) and fewer hemithyroidectomies (36%) were being performed overall; 64.1% of patients stayed 23 hours.CONCLUSION:This is one of the largest series reporting outcomes for outpatient thyroid surgery. Since these surgeries appear to be shifting to an outpatient setting, this report reflects the experience with the majority of endocrine surgeries from the UHC database being performed presently. These results are derived from teaching hospitals and their affiliates and may not reflect the entirety of thyroid surgery in the United States.

Objective. The incidence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in the United States decreased during 2005–2008, but noninvasive community-associated MRSA (CA-MRSA) infections also frequently lead to hospitalization. We estimated the incidence of all MRSA infections among inpatients at US academic medical centers (AMCs) per 1,000 admissions during 2003–2008. Design. Retrospective cohort study. Setting and Participants. Hospitalized patients at 90% of nonprofit US AMCs during 2003–2008. Methods. Administrative data on MRSA infections from a hospital discharge database (University HealthSystem Consortium [UHC]) were adjusted for underreporting of the MRSA V09.0 International Classification of Diseases, Ninth Revision, Clinical Modification code and validated using chart reviews for patients with known MRSA infections in 2004–2005, 2006, and 2007. Results. The mean sensitivity of administrative data for MRSA infections at the University of Chicago Medical Center in three 12-month periods during 2004–2007 was 59.1%. On the basis of estimates of billing data sensitivity from the literature and the University of Chicago Medical Center, the number of MRSA infections per 1,000 hospital discharges at US AMCs increased from 20.9 (range, 11.1–47.7) in 2003 to 41.7 (range, 21.9–94.0) in 2008. At the University of Chicago Medical Center, among infections cultured more than 3 days prior to hospital discharge, CA-MRSA infections were more likely to be captured in the UHC billing-derived data than were healthcare-associated MRSA infections. Conclusions. The number of hospital admissions for any MRSA infection per 1,000 hospital admissions overall increased during 2003–2008. Use of unadjusted administrative hospital discharge data or surveillance for invasive disease far underestimates the number of MRSA infections among hospitalized patients.

BACKGROUND:Antimicrobial stewardship programs are advised to measure and risk-adjust antimicrobial use to facilitate interhospital comparisons, a process called benchmarking. The purpose of this investigation was to evaluate a new benchmarking strategy for antibacterials.METHODS:Hospital-wide adult antibacterial drug use in 2009 was measured as days of therapy (DOT) and length of therapy (LOT) from billing records in 70 US academic medical centers (AMCs). Patients were assigned to 1 of 35 clinical service lines (CSL) based on their Medicare Severity Diagnosis Related Group. Expected (E) use was determined by indirect standardization and compared with observed (O) use.RESULTS:Of 1,791 ,180 discharged adults, 63.7% received antibacterial drugs; the range by CSL was 14.3% (psychiatry) to 99.7% (lung transplant). Mean ± SD hospital-wide use was 839 ± 106 DOTs (range, 594-1109) and 536 ± 53.0 LOT (range, 427-684) per 1000 patient-days. The ventilator support CSL had the most DOT per discharge, 39.4 ± 9.4 days; the LOT was 21.5 ± 4.5 days. The hospital-wide O/E ratio range was 0.7-1.45; in 5 AMCs the ratio exceeded the 90% confidence interval (CI) and was below the 90% CI in 6. Variability in use was explained by the proportion of treated patients within each CSL and mean LOT and DOT per discharge.CONCLUSIONS:Adult antibacterial drug use was benchmarked to expected use adjusted for patient mix, and outlier hospitals were identified. Differences between expected and observed use reflect usage patterns that were benchmarked and are targets for evaluation and intervention.