Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer

2016 ◽  
Vol 12 (10) ◽  
pp. e933-e943 ◽  
Author(s):  
Jeffrey D. Clough ◽  
Larisa M. Strawbridge ◽  
Thomas W. LeBlanc ◽  
Bradley G. Hammill ◽  
Arif H. Kamal
Keyword(s):  
End Of Life ◽  
Patient Outcomes ◽  
Regression Models ◽  
Care Transitions ◽  
Medicare Beneficiaries ◽  
Life Outcomes ◽  
Logistic Regression Models ◽  
Practice Level ◽  
Level Hospital ◽  
Hospital Use

Purpose: To determine the relationships between hospital use of treating oncology practices and patient outcomes. Patients and Methods: Retrospective analysis of 397,646 Medicare beneficiaries who received anticancer therapy in 2012. Each beneficiary was associated with a practice; practices were ranked on the basis of risk-adjusted hospital use, that is, inpatient intensity. Outcomes included 30-day readmission, weekend admissions, intensive care unit stays in the last month of life, and hospice stay of ≥ 7 days. Outcomes were measured for each quartile of practice-level inpatient intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios (ORs) for each outcome for each quartile of inpatient intensity. Results: Total 30-day readmissions were 22.8% and 31.9% (OR, 1.45; 95% CI, 1.39 to 1.50) for patients in practices with the lowest versus highest quartiles of inpatient intensity, respectively; unplanned readmissions were 19.8% and 27.1% (OR, 1.36; 95% CI, 1.31 to 1.41), respectively. The proportion of admissions that occurred on weekends was similar across quartiles. Patients of practices in the highest quartiles of inpatient intensity had higher rates of death in an ICU stay in the last month of life (25.5% versus 18.0%; OR, 1.33; 95% CI, 1.19 to 1.49) and a lower rate of hospice stay of at least 7 days (50.9% to 42.5%; OR, 0.79; 95% CI, 0.74 to 0.86). Conclusion: Medical oncology practices that seek to reduce hospitalizations should consider focusing initially on processes related to end-of-life care and care transitions.

Association of high rates of practice-level inpatient-intensity with end-of-life outcomes, readmission rates, and weekend hospitalizations among Medicare patients with cancer.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 6-6
Author(s):  
Jeffrey D Clough ◽  
Larisa M Strawbridge ◽  
Thomas William LeBlanc ◽  
Bradley G Hammill ◽  
Arif Kamal
Keyword(s):  
Cancer Therapy ◽  
End Of Life ◽  
Medicare Beneficiaries ◽  
Life Outcomes ◽  
Readmission Rates ◽  
Logistic Regression Models ◽  
Practice Level ◽  
Anti Cancer ◽  
Medicare Patients ◽  
Oncology Practice

5 Background: Substantial practice-level variation exists in use of acute hospital care for patients receiving anti-cancer therapy. The aim of this study was to determine whether patient outcomes were associated with greater inpatient-intensity at the treating practices. Methods: Retrospective analysis of 397,646 Medicare beneficiaries receiving anti-cancer therapy in 2012. Each beneficiary was associated with a practice and practices were ranked based on average payments for inpatient admissions (inpatient intensity). Outcomes included 30-day readmission, weekend admissions, intensive-care unit (ICU) stays in the last month of life, and hospice stay of at least 7 days. Outcomes were measured for each quartile of practice inpatient-intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios for each outcome for each quartile of inpatient-intensity. Results: Total and unplanned 30-day readmissions increased from 22.8% to 31.9% (adjusted odds ratio and 95% confidence interval: 1.45 [1.39-1.50]) and 19.8% to 27.1% (1.36 [1.31-1.41]), respectively, for patients in practices in the lowest and highest quartiles of inpatient-intensity. The proportion of admissions occurring on the weekend was similar across quartiles. The proportion of decedents with an ICU stay in the last month of life increased from 18.0% to 25.5% (1.33, 1.19–1.49) while the proportion with a hospice stay of > = 7 days decreased from 50.9% to 42.5% (0.79, 0.74–0.86) between those in practices in the lowest and highest quartiles of inpatient intensity. Conclusions: Participants in oncology practice delivery reform may find significant opportunity to improve quality and reduce costs by initially focusing on processes related to improving end-of-life care and reducing readmissions.

Surgical oncology outcomes: The role of nurse practice environments

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 6105-6105
Author(s):  
C. R. Friese ◽  
L. H. Aiken
Keyword(s):  
Logistic Regression ◽  
Patient Outcomes ◽  
Regression Models ◽  
Surgical Oncology ◽  
Cancer Center ◽  
Practice Environment ◽  
Failure To Rescue ◽  
Oncology Patient ◽  
Logistic Regression Models

6105 Background: Increased attention has focused on the role of hospital characteristics on cancer patient outcomes. We examined two cancer-specific credentials, as well registered nurse practice environments, on outcomes of care. Methods: Through secondary analysis of existing data from hospital claims, the tumor registry, and a statewide of survey of nurses (RNs), we studied 30-day mortality (D) and failure to rescue (death given a complication) (FTR) for surgical oncology patients treated in 164 Pennsylvania hospitals from 1998–1999 (N=24,618). We compared D and FTR rates by a hospital’s NCI cancer center designation, American College of Surgeon’s (ACoS) cancer program approval and categorized scores on the Practice Environment Scale of the Nursing Work Index (PES-NWI). The PES-NWI scales measure RN participation in hospital affairs, RN foundations for quality of care, nurse manager leadership/support, staffing/resource adequacy, and RN-physician relations. Multivariate logistic regression models examined predictors of D and FTR, controlling for 25 patient variables. Standard errors were corrected for patient clustering in hospitals. Results: NCI centers had lower D and FTR rates (p < .01). ACoS hospitals had lower D and FTR rates (ns). Hospitals with low scores on PES-NWI scales had the poorest outcomes (p < .01). In logistic regression models, significant predictors included unfavorable PES-NWI Scores for D (OR=1.32, 95% CI: 1.06–1.65) and FTR (OR=1.39, 95% CI:1.03–1.88), and NCI centers for D (OR=0.64, 95% CI: 0.50–0.83) and FTR (OR=0.67, 95% CI: 0.47–0.96). The NCI effect lost significance when environment was included. ACoS program effects were small (OR= 0.99, p = .90) for both outcomes. Conclusions: Favorable outcomes in NCI centers may be partly explained by practice environments. The practice environment of RNs significantly predicts surgical oncology patient outcomes, and should be a focus of quality improvement activities. No significant financial relationships to disclose.

scholarly journals LO10: Associations between ED crowding metrics and 72h-hour ED re-visits: Which crowding metrics are most highly associated with patient-oriented adverse outcomes?

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S10
Author(s):  
A. McRae ◽  
G. Innes ◽  
M. Schull ◽  
E. Lang ◽  
E. Grafstein ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Regression Models ◽  
Information Criterion ◽  
Patient Characteristics ◽  
Adverse Outcomes ◽  
Logistic Regression Models ◽  
Return Visits ◽  
Offload Delay ◽  
Ed Crowding ◽  
Meaningful Measure

Introduction: Emergency Department (ED) crowding is a pervasive problem and is associated with adverse patient outcomes. Yet, there are no widely accepted, universal ED crowding metrics. The objective of this study is to identify ED crowding metrics with the strongest association to the risk of ED revisits within 72 hours, which is a patient-oriented adverse outcome. Methods: Crowding metrics, patient characteristics and outcomes were obtained from administrative data for all ED encounters from 2011-2014 for three adult EDs in Calgary, AB. The data were randomly divided into three partitions for cross-validation, and further divided by CTAS category 1, 2/3 and 4/5. Twenty unique ED crowding metrics were calculated and assigned to each patient seen on each calendar day or shift, to standardize the exposure. Logistic regression models were fitted with 72h ED revisit as the dependent variable, and an individual crowding metric along with a common list of confounders as independent variables. Adjusted odds ratios (OR) for the 72h return visits were obtained for each crowding metric. The strength of associations between 72h revisits and crowding metrics were compared using Akaike's Information Criterion and Akaike weights. Results: This analysis is based on 1,149,939 ED encounters. Across all CTAS groups, INPUT metrics (ED census, ED occupancy, waiting time, EMS offload delay, LWBS%) were only weakly associated with the risk of 72h re-visit. Among THROUGHPUT metrics, ED Length of Stay and MD Care Time had similar adjusted ORs for 72h ED re-visit (range 0.99-1.15). Akaike weights ranging from 0.3/1.00 to 0.4/1.00 indicate that both THROUGHPUT metrics are reasonable predictors of 72h ED re-visits. All OUTPUT metrics (boarding time, # of boarded patients, % of beds occupied by boarded patients, hospital occupancy) had statistically significant ORs for 72h ED re-visits. The median boarding time had the highest adjusted OR for 72h ED re-visit (adjusted OR 1.40, 95% CI 1.33-1.47) and highest Akaike weight (0.97/1.00) compared to all other OUTPUT metrics, indicating that median boarding time had the strongest association with 72h re-visits. Conclusion: ED THROUGHPUT and OUTPUT metrics had consistent associations with 72h ED re-visits, while INPUT metrics had little to no association with 72h re-visits. Median boarding time is the strongest predictor of 72h re-visits, indicating that this may be the most meaningful measure of ED crowding.

What Becomes of Chronic Juvenile Delinquents? Multifinality at Midlife

2019 ◽  
Vol 18 (2) ◽  
pp. 119-134
Author(s):  
Alan J. Drury ◽  
Matt DeLisi ◽  
Michael J. Elbert
Keyword(s):  
Traumatic Brain Injury ◽  
Mental Illness ◽  
Brain Injury ◽  
Juvenile Delinquents ◽  
Regression Models ◽  
Developmental Psychopathology ◽  
Initial Condition ◽  
Life Outcomes ◽  
Logistic Regression Models ◽  
Gang Activity

Popular in the field of developmental psychopathology, multifinality means that an initial condition or status can manifest in diverse outcomes across life. Using a near population of federal correctional clients selected from the Midwestern United States, the current study examined the association of chronic delinquent offender status on assorted life outcomes at midlife (average age of offenders was nearly 44 years). Although just 16% of the current offenders were formerly chronic delinquents, they accounted for 13.9% of current employment, 54.6% of antisocial personality disorder (ASPD) cases, 54% of those at the 90th percentile for arrest charges, 45.8% of those at the 90th percentile for assaultive arrest charges, 53% of gang activity, 43.8% of lifetime traumatic brain injury, and 22.9% of lifetime mental illness. Logistic regression models indicated that former chronic delinquency was associated with 41% reduced odds of employment, 897% increased odds of ASPD, 81% increased odds of 90th percentile offending, 82% increased odds of 90th percentile assaultive offending, 144% increased odds of gang activity, 115% increased odds of traumatic brain injury, and 141% increased odds of lifetime mental illness. Former chronic delinquency has more consistent predictive validity among males than females and among Whites than African Americans. Multifinality is a useful concept to understand the developmental course of chronic delinquency and assess noncriminal yet nevertheless socially and societally burdensome outcomes.

Do advance directives predict receipt of palliative care? An evaluation of a single-institution in the Veterans Administration health care system.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 203-203
Author(s):  
Manali I. Patel ◽  
Jay Bhattacharya ◽  
Steven M Asch ◽  
James Kahn
Keyword(s):  
Palliative Care ◽  
Logistic Regression ◽  
End Of Life ◽  
Advanced Cancer ◽  
Advance Directives ◽  
Regression Models ◽  
Stage Iii ◽  
Veterans Administration ◽  
Clinical Factors ◽  
Logistic Regression Models

203 Background: Cancer-related deaths are often preceded by high utilization of non-beneficial care that may contribute to poor quality of life, adverse symptoms, and high costs. Over the past several years, there is increased attention on palliative care to limit these challenges. Yet, rates of palliative care referral at the end of life remain low, and there are few studies that evaluate why. Our objective is to study whether one potentially important factor among patients with advanced cancer, advance directives, influence referral to palliative care among patients with advanced cancer. Methods: We conducted a retrospective chart review of all patients diagnosed with Stage III and IV cancers and treated at the Veterans Administration Palo Alto Healthcare System (VAPAHCS) in Fiscal Year 2012-2013. Chi-squared tests estimated differences in receipt of palliative care by individual- and clinical-factors. Logistic regression models estimated odds of receipt of palliative care after adjustment for individual and clinical factors). Results: There were 276 patients diagnosed with Stage III and IV cancer during the years of study. No records were excluded from analysis. Median age at diagnosis was 68; thoracic cancers were the most common (31%, p = 0.001). A minority of patients (45%) received palliative care or hospice. Rates of referral to palliative care and hospice were highest among patients with stage IV disease (p=0.003). In logistic regression models adjusted for individual and clinical factors only stage of disease predicted increased odds of palliative care and hospice referral. We could not reject the null hypothesis that presence of an advance directive increased palliative care or hospice treatment. Conclusions: Advance directives may be a useful tool to help patients transition to palliative care and hospice, however, we found no influence of advance directives on the receipt of these services in our VA facility. Future studies should evaluate other factors that predict receipt of high quality end-of-life care for patients with cancer.

The impact of SPY angiography on intraoperative decision making and outcomes for post-mastectomy reconstruction

2019 ◽  
pp. 1-5
Keyword(s):  
Decision Making ◽  
Logistic Regression ◽  
Skin Necrosis ◽  
Regression Models ◽  
Multivariable Analysis ◽  
P Value ◽  
Flap Necrosis ◽  
Single Institution ◽  
Logistic Regression Models ◽  
The Impact

Objective: While the use of intraoperative laser angiography (SPY) is increasing in mastectomy patients, its impact in the operating room to change the type of reconstruction performed has not been well described. The purpose of this study is to investigate whether SPY angiography influences post-mastectomy reconstruction decisions and outcomes. Methods and materials: A retrospective analysis of mastectomy patients with reconstruction at a single institution was performed from 2015-2017.All patients underwent intraoperative SPY after mastectomy but prior to reconstruction. SPY results were defined as ‘good’, ‘questionable’, ‘bad’, or ‘had skin excised’. Complications within 60 days of surgery were compared between those whose SPY results did not change the type of reconstruction done versus those who did. Preoperative and intraoperative variables were entered into multivariable logistic regression models if significant at the univariate level. A p-value <0.05 was considered significant. Results: 267 mastectomies were identified, 42 underwent a change in the type of planned reconstruction due to intraoperative SPY results. Of the 42 breasts that underwent a change in reconstruction, 6 had a ‘good’ SPY result, 10 ‘questionable’, 25 ‘bad’, and 2 ‘had areas excised’ (p<0.01). After multivariable analysis, predictors of skin necrosis included patients with ‘questionable’ SPY results (p<0.01, OR: 8.1, 95%CI: 2.06 – 32.2) and smokers (p<0.01, OR:5.7, 95%CI: 1.5 – 21.2). Predictors of any complication included a change in reconstruction (p<0.05, OR:4.5, 95%CI: 1.4-14.9) and ‘questionable’ SPY result (p<0.01, OR: 4.4, 95%CI: 1.6-14.9). Conclusion: SPY angiography results strongly influence intraoperative surgical decisions regarding the type of reconstruction performed. Patients most at risk for flap necrosis and complication post-mastectomy are those with questionable SPY results.

Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution

2020 ◽  
Vol 16 (32) ◽  
pp. 2635-2643
Author(s):  
Samantha L Freije ◽  
Jordan A Holmes ◽  
Saleh Rachidi ◽  
Susannah G Ellsworth ◽  
Richard C Zellars ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Odds Ratio ◽  
Regression Models ◽  
Tumor Patients ◽  
Logistic Regression Models ◽  
Factors Associated ◽  
Follow Up Care ◽  
Risk Patients ◽  
African American Race

Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African–American race (odds ratio [OR] 1.33; 95% CI: 1.17–1.51), Medicaid insurance (OR 1.59; 1.36–1.87), no insurance (OR 1.66; 1.32–2.10) and rural residence (OR 1.78; 1.49–2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.

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