Comparing Resource Use in Medical Admissions of Children With Complex Chronic Conditions.

Background: Children with complex chronic conditions (CCCs) utilize a disproportionate share of hospital resources.

Objective: We asked whether some hospitals display a significantly different pattern of resource utilization than others when caring for similar children with CCCs admitted for medical diagnoses.

Research Design: Using Pediatric Health Information System data from 2009 to 2013, we constructed an inpatient Template of 300 children with CCCs, matching these to 300 patients at each hospital, thereby performing a type of direct standardization.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules.

Background: Concern persists that extended shifts in medical residency programs may adversely affect patient safety.

Methods: We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts.

Disparities in Breast Cancer Survival by Socioeconomic Status Despite Medicare and Medicaid Insurance.

Unlabelled: Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine.

Introduction: Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness.

Adjustment for Atherosclerosis Diagnosis Distorts the Effects of Percutaneous Coronary Intervention and the Ranking of Hospital Performance.

Background: Coronary atherosclerosis raises the risk of acute myocardial infarction (AMI), and is usually included in AMI risk-adjustment models. Percutaneous coronary intervention (PCI) does not cause atherosclerosis, but may contribute to the notation of atherosclerosis in administrative claims. We investigated how adjustment for atherosclerosis affects rankings of hospitals that perform PCI.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.

Background: Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.

Methods: We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.

Comparing Outcomes between Antibody Induction Therapies in Kidney Transplantation.

Kidney transplant recipients often receive antibody induction. Previous studies of induction therapy were often limited by short follow-up and/or absence of information about complications. After linking Organ Procurement and Transplantation Network data with Medicare claims, we compared outcomes between three induction therapies for kidney recipients.

Outcomes, ICU Use, and Length of Stay in Chronically Ill Black and White Children on Medicaid and Hospitalized for Surgery.

Background: With increasing Medicaid coverage, it has become especially important to determine whether racial differences exist within the Medicaid system. We asked whether disparities exist in hospital practice and patient outcomes between matched black and white Medicaid children with chronic conditions undergoing surgery.

Study Design: We conducted a matched cohort study, matching 6,398 pairs within states on detailed patient characteristics using data from 25 states contributing adequate Medicaid Analytic eXtract claims for admissions of children with chronic conditions undergoing the same surgical procedures between January 1, 2009 and November 30, 2010 for ages 1 to 18 years.

Racial Disparities in Medicaid Asthma Hospitalizations.

Background And Objectives: Black children with asthma comprise one-third of all asthma patients in Medicaid. With increasing Medicaid coverage, it has become especially important to monitor Medicaid for differences in hospital practice and patient outcomes by race.

Methods: A multivariate matched cohort design, studying 11 079 matched pairs of children in Medicaid (black versus white matched pairs from inside the same state) admitted for asthma between January 1, 2009 and November 30, 2010 in 33 states contributing adequate Medicaid Analytic eXtract claims.

Practice Style Variation in Medicaid and Non-Medicaid Children With Complex Chronic Conditions Undergoing Surgery.

Objectives: With differential payment between Medicaid and Non-Medicaid services, we asked whether style-of-practice differs between similar Medicaid and Non-Medicaid children with complex chronic conditions (CCCs) undergoing surgery.

Summary Of Background Data: Surgery in children with CCCs accounts for a disproportionately large percentage of resource utilization at major children's hospitals.

Methods: A matched cohort design, studying 23,582 pairs of children with CCCs undergoing surgery (Medicaid matched to Non-Medicaid within the same hospital) from 2009 to 2013 in 41 Children's Hospitals.

Auditing Practice Style Variation in Pediatric Inpatient Asthma Care.

Importance: Asthma is the most prevalent chronic illness among children, remaining a leading cause of pediatric hospitalizations and representing a major financial burden to many health care systems.

Objective: To implement a new auditing process examining whether differences in hospital practice style may be associated with potential resource savings or inefficiencies in treating pediatric asthma admissions.

Design, Setting, And Participants: A retrospective matched-cohort design study, matched for asthma severity, compared practice patterns for patients admitted to Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System (PHIS) database.

Practice Patterns in Medicaid and Non-Medicaid Asthma Admissions.

Background And Objectives: With American children experiencing increased Medicaid coverage, it has become especially important to determine if practice patterns differ between Medicaid and non-Medicaid patients. Auditing such potential differences must carefully compare like patients to avoid falsely identifying suspicious practice patterns. We asked if we could observe differences in practice patterns between Medicaid and non-Medicaid patients admitted for asthma inside major children's hospitals.

Measures of Global Health Status on Dialysis Signal Early Rehospitalization Risk after Kidney Transplantation.

Background: Early rehospitalization (<30 days) after discharge from kidney transplantation (KT) is associated with poor outcomes. We explored summary metrics of pre-transplant health status that may improve the identification of KT recipients at risk for early rehospitalization and mortality after transplant.

Materials And Methods: We performed a retrospective cohort study of 8,870 adult (≥ 18 years) patients on hemodialysis who received KT between 2000 and 2010 at United States transplant centers.

Improving Medicare's Hospital Compare Mortality Model.

Objective: To improve the predictions provided by Medicare's Hospital Compare (HC) to facilitate better informed decisions regarding hospital choice by the public.

Data Sources/setting: Medicare claims on all patients admitted for Acute Myocardial Infarction between 2009 through 2011.

Study Design: Cohort analysis using a Bayesian approach, comparing the present assumptions of HC (using a constant mean and constant variance for all hospital random effects), versus an expanded model that allows for the inclusion of hospital characteristics to permit the data to determine whether they vary with attributes of hospitals, such as volume, capabilities, and staffing.

Indirect Standardization Matching: Assessing Specific Advantage and Risk Synergy.

Objective: To develop a method to allow a hospital to compare its performance using its entire patient population to the outcomes of very similar patients treated elsewhere.

Data Sources/setting: Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006.

Study Design: Using two example "focal" hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals.

Comparison of the Value of Nursing Work Environments in Hospitals Across Different Levels of Patient Risk.

Importance: The literature suggests that hospitals with better nursing work environments provide better quality of care. Less is known about value (cost vs quality).

Objectives: To test whether hospitals with better nursing work environments displayed better value than those with worse nursing environments and to determine patient risk groups associated with the greatest value.

Examining Causes of Racial Disparities in General Surgical Mortality: Hospital Quality Versus Patient Risk.

Background: Racial disparities in general surgical outcomes are known to exist but not well understood.

Objectives: To determine if black-white disparities in general surgery mortality for Medicare patients are attributable to poorer health status among blacks on admission or differences in the quality of care provided by the admitting hospitals.

Research Design: Matched cohort study using Tapered Multivariate Matching.

Racial disparities in colon cancer survival: a matched cohort study.

Background: Differences in colon cancer survival by race are a recognized problem among Medicare beneficiaries.

Objective: To determine to what extent the racial disparity in survival is due to disparity in presentation characteristics at diagnosis or disparity in subsequent treatment.

Design: Black patients with colon cancer were matched with 3 groups of white patients: a "demographic characteristics" match controlling for age, sex, diagnosis year, and Survey, Epidemiology, and End Results (SEER) site; a "presentation" match controlling for demographic characteristics plus comorbid conditions and tumor characteristics, including stage and grade; and a "treatment" match, including presentation variables plus details of surgery, radiation, and chemotherapy.

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.

Importance: Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.

Objective: To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.

Design, Setting, And Participants: Observational study of Medicare patient admissions (6,384,273 admissions from 2,790,356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery.

A hospital-specific template for benchmarking its cost and quality.

Objective: Develop an improved method for auditing hospital cost and quality tailored to a specific hospital's patient population.

Data Sources/setting: Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, New York, and Texas between 2004 and 2006.

Study Design: A template of 300 representative patients from a single index hospital was constructed and used to match 300 patients at 43 hospitals that had a minimum of 500 patients over a 3-year study period.

Template matching for auditing hospital cost and quality.

Objective: Develop an improved method for auditing hospital cost and quality.

Data Sources/setting: Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, Texas, and New York between 2004 and 2006.

Study Design: A template of 300 representative patients was constructed and then used to match 300 patients at hospitals that had a minimum of 500 patients over a 3-year study period.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores.

Purpose: To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

Method: The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

Characteristics associated with differences in survival among black and white women with breast cancer.

Importance: Difference in breast cancer survival by race is a recognized problem among Medicare beneficiaries.

Objective: To determine if racial disparity in breast cancer survival is primarily attributable to differences in presentation characteristics at diagnosis or subsequent treatment.

Design, Setting, And Patients: Comparison of 7375 black women 65 years and older diagnosed between 1991 to 2005 and 3 sets of 7375 matched white control patients selected from 99,898 white potential controls, using data for 16 US Surveillance, Epidemiology and End Results (SEER) sites in the SEER-Medicare database.

Racial disparities in operative procedure time: the influence of obesity.

Background: Using Pennsylvania Medicare claims from 1995 to 1996, the authors previously reported that anesthesia procedure length appears longer in blacks than whites. In a new study using a different and larger data set, the authors now examine whether body mass index (BMI), not available in Medicare claims, explains this difference. The authors also examine the relative contributions of surgical and anesthesia times.