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In 2014 the California legislature passed Senate Bill 1004 (SB 1004) that was designed to expand access to specialty palliative care for individuals served by California's Medicaid (known as Medi-Cal) Managed Care Plans (MCPs). The California Department of Health Care Services (DHCS) operationalized the legislation by developing minimum requirements for palliative care programs that all MCPs must meet or exceed. 7 Quality and utilization data specific to California's Medicaid population are needed for stakeholders to identify care deficiencies and disparities, describe the end of life experience and utilization patterns of MCP members, compare these patterns to Medicare beneficiaries or other populations, and set appropriate targets to help monitor progress. We evaluated the feasibility of using Medicaid claims data and encounter data either by partnering with MCPs or by obtaining statewide data from DHCS to measure the quality of palliative care and end of life care. In a concurrent but separate effort, we analyzed administrative data supplied by three MCPs as part of a prospective pilot of standards for home-based palliative care in California, including care delivered to Medicaid beneficiaries under SB 1004. Beyond the practical challenges of allowing time for data access and approvals, both projects revealed several limitations to using administrative data to assess quality of palliative and end of life care for a Medicaid population. We describe these challenges that undermined our confidence in analysis results and propose solutions to measuring the quality of palliative and end of life care for Medicaid patients and suggested next steps., Competing Interests: Disclosures and Acknowledgments The authors would like to acknowledge Katherine Santos for her administrative work on this paper. Dr. Zingmond, Dr. Walling, Dr. Wenger (awards G-30966 and G-31311), Dr. Cassel, and Ms. Kerr (awards G-20493, and G-20495) were supported by the California Health Care Foundation. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. Funding: Dr. Garcia-Jimenez has nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population., Objective: Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California., Design: Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims., Patients: California nursing home residents with Medicare fee-for-service insurance, 2011-2016., Main Measures: Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics., Key Results: The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization., Conclusions: Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents., (© 2023. The Author(s).)

Background: Gallstones are a common problem in the United States with many patients suffering from symptomatic cholelithiasis (SC). Patients with SC may first present to the emergency department ED) and are often discharged for elective follow-up; however, it is unknown what system and patient factors are associated with increased risk for ED revisits. This study aimed to assess longitudinal ED utilization and cholecystectomy for patients with SC and identify patient, geographic, and hospital characteristics associated with ED revisits, specifically race/ethnicity and insurance status., Methods: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Emergency department revisits and cholecystectomy after discharge were examined using logistic regression, clustering standard errors by hospital. Models adjusted for patient, geographic, and hospital variables using census and hospital administrative data., Results: Cohort included 34,427 patients who presented to the ED with SC and were discharged. There were 18.8% of the patients that had one or more biliary-related ED revisits within 1 year. In fully adjusted models, non-Hispanic Black patients had higher odds for any ED revisit (adjusted odds ratio 1.23; 95% confidence interval, 1.09-1.39) and for two more ED revisits (adjusted odds ratio 1.48; 95% confidence interval, 1.20-1.82). Insurance type was also associated with ED revisits., Conclusion: Non-Hispanic Black patients experienced higher utilization of health care resources for SC after adjusting for other patient, geographic and hospital variables. Strategies to mitigate these disparities may include the development of standardized protocols regarding the follow-up and education for SC. Implementation of such strategies can ensure equitable treatment for all patients., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Timely receipt of surgery should be available for all patients. Few studies have examined differences in the treatment of symptomatic cholelithiasis (SC), a common surgical problem, based on race/ethnicity or insurance status. This study aimed to identify differences in repeat emergency department (ED) use and wait time to cholecystectomy for SC., Study Design: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Repeat ED use and wait time to elective and nonelective cholecystectomy after ED discharge were examined using logistic and negative binomial regression models., Results: The final cohort analyzed 13,596 patients who underwent cholecystectomy within 1 year from index ED visit for SC. In adjusted analysis, non-Hispanic Black patients had higher odds for repeat ED use for biliary-related conditions before elective surgery and experienced longer waits for cholecystectomy (across several measures of wait times) compared with non-Hispanic White patients. Similar findings were seen for Medicaid and self-pay compared with privately insured patients. For example, self-pay patients had more than double the odds of experiencing repeat ED use while waiting for elective cholecystectomy compared with privately insured patients (adjusted odds ratio 2.49, 95% CI 1.88-3.31)., Conclusion: Patients with SC receiving cholecystectomy within 1 year from index ED visit were more likely to have repeat ED use and longer waits to surgery based on their race/ethnicity and insurance status, even after adjusting for other measures of access. We identify a vulnerable population at risk for differences in treatment for a common surgical pathology., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients' life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016., Methods: California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross-sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed-effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five-star quality rating., Results: POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short-stay:68%; long-stay:81%). Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five-star facility quality rating was associated with greater POLST completion., Conclusions: Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long-stay residents have orders to limit life-sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST., (© 2022 The American Geriatrics Society.)

Purpose: Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes., Methods: Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology., Results: In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital., Conclusion: There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.

Background: Physician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care., Objective: To evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility., Design: Observational study using California Minimum Data Set Section S., Participants: A total of 296,276 people with a stay in 1,220 California nursing homes in 2011., Main Measures: The proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes., Key Results: During 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid., Conclusions: Statewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement., Competing Interests: All of the authors declare that they have no conflicts of interest with regard to this manuscript.

For patients suffering from diabetes and other chronic conditions, a large body of work demonstrates income-related disparities in access to coordinated preventive care. Much less is known about associations between poverty and consequential negative health outcomes. Few studies have assessed geographic patterns that link household incomes to major preventable complications of chronic diseases. Using statewide facility discharge data for California in 2009, we identified 7,973 lower-extremity amputations in 6,828 adults with diabetes. We mapped amputations based on residential ZIP codes and used data from the Census Bureau to produce corresponding maps of poverty rates. Comparisons of the maps show amputation "hot spots" in lower-income urban and rural regions of California. Prevalence-adjusted amputation rates varied tenfold between high-income and low-income regions. Our analysis does not support detailed causal inferences. However, our method for mapping complication hot spots using public data sources may help target interventions to the communities most in need., (Project HOPE—The People-to-People Health Foundation, Inc.)

California mandates hospitals to collect and report patient race, ethnicity, and primary spoken language (REL). A lack of specific guidelines and standardized practices on how data should be collected has contributed to inconsistent and incomplete data.General acute care hospitals in California completed a survey to elucidate practices regarding collection and auditing of patient REL. Nearly all hospitals reported collecting race and/or ethnicity (97%). The majority of hospitals used standardized forms for collection, and 75% audited patient information for completeness. Popular accepted strategies to improve the quality and completeness of REL included collecting data at the first encounter, routine staff training, incorporating REL questions into existing admissions forms, and developing and enforcing hospital policies regarding data collection.California hospitals are collecting information on patient REL as mandated, but variation in data collection exists. Hospitals endorse many reasonable approaches for standardization, and may benefit from standardized data collection and auditing practices.

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions., Methods: We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission., Results: We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00)., Conclusions: Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.

Physician Orders for Life-Sustaining Treatment (POLST) is a tool to document and ensure continuity of end-of-life treatment decisions across healthcare settings that became a legal document in California in January 2009. Hospitals were surveyed to evaluate factors associated with uptake of this intervention and whether a grassroots community coalition intervention facilitated dissemination. A mail and telephone survey of all acute care hospitals in California was conducted between August 2011 and January 2012, and community coalition reports of interaction with hospitals and hospital characteristics from the California Office of Statewide Planning and Development and Census ZIP Code Tabulation Areas were analyzed. Of 349 hospitals, 286 (81.9%) responded to the survey. Sixty-five percent of hospitals had a policy about POLST, 87% had available blank POLST forms, 84% had educated staff, and 94% reported handling POLST properly in the emergency department and on admission. In multivariable analyses, hospitals in poor areas and for-profit (vs nonprofit) hospitals were less likely to stock blank POLST forms and to have educated staff, and hospitals with community coalition interaction and in wealthier areas were more likely to handle POLST forms correctly. Although POLST is widely used in California, a significant minority of hospitals remain unprepared 3 years after implementation. Efforts to improve implementation should emphasize dissemination in poorer areas and in for-profit hospitals., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Study Objective: Hospitalizations that occur shortly after emergency department (ED) discharge may reveal opportunities to improve ED or follow-up care. There currently is limited, population-level information about such events. We identify hospital- and visit-level predictors of bounce-back admissions, defined as 7-day unscheduled hospital admissions after ED discharge., Methods: Using the California Office of Statewide Health Planning and Development files, we conducted a retrospective cohort analysis of adult (aged >18 years) ED visits resulting in discharge in 2007. Candidate predictors included index hospital structural characteristics such as ownership, teaching affiliation, trauma status, and index ED size, along with index visit patient characteristics of demographic information, day of service, against medical advice or eloped disposition, insurance, and ED primary discharge diagnosis. We fit a multivariable, hierarchic logistic regression to account for clustering of ED visits by hospitals., Results: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Bounce-back admission within 7 days occurred in 130,526 (2.6%) visits and was associated with Medicaid (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.40 to 1.45) or Medicare insurance (OR 1.53; 95% CI 1.50 to 1.55) and a disposition of leaving against medical advice or before the evaluation was complete (OR 1.90; 95% CI 1.89 to 2.0). The 3 most common age-adjusted index ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, not end stage (OR 3.3; 95% CI 2.8 to 3.8), end-stage renal disease (OR 2.9; 95% CI 2.4 to 3.6), and congestive heart failure (OR 2.5; 95% CI 2.3 to 2.6). Hospital characteristics associated with a higher bounce-back admission rate were for-profit status (OR 1.2; 95% CI 1.1 to 1.3) and teaching affiliation (OR 1.2; 95% CI 1.0 to 1.3)., Conclusion: We found 2.6% of discharged patients from California EDs to have a bounce-back admission within 7 days. We identified vulnerable populations, such as the very old and the use of Medicaid insurance, and chronic or end-stage renal disease as being especially at risk. Our findings suggest that quality improvement efforts focus on high-risk individuals and that the disposition plan of patients consider vulnerable populations., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients., Methods: We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding., Results: We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs., Conclusion: Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients., (Copyright © 2012 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

It is well documented that racial and ethnic minority populations disproportionately use hospital emergency departments for safety-net care. But what is not known is whether emergency department crowding is disproportionately affecting minority populations and potentially aggravating existing health care disparities, including poorer outcomes for minorities. We examined ambulance diversion, a proxy measure for crowding, at 202 California hospitals. We found that hospitals serving large minority populations were more likely to divert ambulances than were hospitals with a lower proportion of minorities, even when controlling for hospital ownership, emergency department capacity, and other hospital demographic and structural factors. These findings suggest that establishing more-uniform criteria to regulate diversion may help reduce disparities in access to emergency care.

Study Objective: The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates., Methods: We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits., Results: We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status., Conclusion: Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Hypothesis: Shoulder arthroplasty is an effective treatment for arthritic conditions and intraarticular fractures of the proximal humerus. Treatment options include total and hemiarthroplasty of the shoulder. They hypothesis of this study was that a mandatory statewide discharge database could identify the epidemiology of primary shoulder arthroplasty, 90 day complication rates, implant survival rates, and patient and hospital characteristics associated with complications., Materials and Methods: We identified patients undergoing primary total shoulder replacement and hemiarthroplasty between 1995 and 2005. We report rates of complications within 90 days of surgery and performed survival analysis using revision surgery as the endpoint. Logistic and proportional hazard regression models were used to estimate the effect of patient and provider factors in predicting the rates of adverse outcomes., Results: During the study period, 15,288 patients underwent shoulder arthroplasty. Patients undergoing total shoulder arthroplasty and hemiarthroplasty had no statistically significant difference in the aggregate risk of 90-day complications or the risk of implant failure within the study period. Fracture patients were shown to have a higher risk of short-term complications (odds ratio, 3.2; P < .001). Implant failure rates were lower in patients with fracture, rheumatoid arthritis, increased comorbidity, and advanced age., Conclusion: This study reports similar rates of short-term complications and implant failure in patients undergoing total or hemiarthroplasty, an overall mortality rate of 1.3%, and a pulmonary embolism rate of 0.6%. The findings of our study indicate that the risk of short-term complications is highest in patients undergoing total or hemiarthroplasty for a fracture compared with nonfracture indications. Our results also indicate that longer-term, implant survival is largely driven by factors associated with increased activity, such as age. In patients undergoing surgery for arthritis of the shoulder, we found no difference in implant survival rates between total and hemiarthroplasty of the shoulder., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Purpose: To determine the complication rates after total elbow arthroplasty (TEA) in a large and diverse patient population., Methods: We identified patients undergoing TEA as inpatients in the years 1995 to 2005 using California's Discharge Database. Short-term outcomes of interest included rates of infection or wound complications, revision, reoperation, and pulmonary embolism that were diagnosed during an inpatient hospital admission and mortality within 90 days of index surgery. Longer-term outcomes analyzed included rates of revision, amputation, and conversion to fusion. We used regression models to estimate the role of patient and provider characteristics in predicting the rates of adverse outcomes., Results: We identified 1,625 patients undergoing TEA. Early complications, defined as those requiring inpatient re-admission within the first 90 days after index surgery, were identified in 170 patients, and 132 patients required reoperation. Eighty one patients required revision in 90 days, and 48 underwent revision within one year. Early infections and wound complications requiring readmission occurred in 88 patients. In the 90 days after surgery, 4 patients had a pulmonary embolism and 10 patients died. One-hundred and twenty-one patients required revision, amputation, or fusion during the observation period, with a mean follow-up of 4 years. Hospital volume was not associated with increased risk of adverse outcomes., Conclusions: We analyzed a large and diverse patient population undergoing TEA. The overall rate of short-term complications requiring inpatient treatment was high, at over 10% (170 patients), with almost 8% (132 patients) requiring reoperation within the first 90 days. Although population-based studies have shortcomings, they can add to the body of knowledge of less frequent procedures such as TEA., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2011. Published by Elsevier Inc.)

Background: One of the cornerstones of ovarian cancer therapy is cytoreductive surgery, which can be performed by surgeons with different specialty training. We examined whether surgeon specialty impacts quality of life (as proxied by presence of ostomy) and overall survival for women with advanced ovarian cancer., Methods: Stage IIIC/IV ovarian cancer patients were identified using 4 state cancer registries: California, Washington, New York, and Florida and linked records to the corresponding inpatient-hospital discharge file, AMA Masterfile, and 2000 U.S. Census SF4 File. Predictors of receipt of care by a general surgeon and creation of fecal ostomy were analyzed. Multivariate modeling was performed to assess the association of hospital volume (low volume (LV) [0-4 cases], middle volume (MV) [5-9], high volume (HV) [10-19], and very high volume (VHV) [20+]) and surgeon specialty training (gynecologic oncologists/gynecologists, general surgeons, and other specialty) on survival., Results: We identified 31,897 Stage IIIC/IV patients; mean age was 64 years. Treatment of patients by a general surgeon was predicted by LV, rural patient residence, poverty, and high level of comorbidity. Patients had lower hazard of death when treated in higher volume hospitals as compared to LV [VHV hazard ratio (HR)=0.79, P<.0001; HV HR=0.89, P<0.001]. Patients treated by a general surgeon had higher likelihood of an ostomy (OR=4.46, P<.0001) and hazard of death (HR=1.63, P<.0001) compared to gynecologic oncologist/gynecologist., Conclusions: Advanced stage ovarian cancer patients have better survival when treated by gynecologic oncology/gynecology trained surgeons. Data suggest that referral to these specialists may optimize surgical debulking and minimize the creation of a fecal ostomy., (Copyright 2010 Elsevier Inc. All rights reserved.)

Introduction: The impact of socioeconomic status-income and acculturation-on hip fracture is not well understood. We studied 116,919 fractures among 8,144,469 people in California. Greater income and English fluency predict lower fracture incidence. Lower income and immigrant populations are at increased risk for hip fracture and require intervention. Race/ethnicity is a major determinant of hip fracture risk. Although socioeconomic status (e.g., income and acculturation) is often associated with race/ethnicity, its impact on hip fracture incidence is less well understood., Methods: We carried out a retrospective, population-based, study of persons with hip fractures in California, 1996 to 2000, compared to census estimates by zip code. We performed Poisson regression analyses to calculate hip fracture incident rate ratios for gender, age, race/ethnicity, income, language (percent non-English speakers)-a proxy for acculturation-and living in rural areas., Results: During the 5-year period, 116,919 fractures occurred among 8,144,469 persons (2.87 fractures/1,000 persons per year). Higher income predicted lower hip fracture incidence. Persons in the highest decile of estimated income had an incident rate ratio (IRR) of 0.79 (95% confidence interval (CI) 0.77 to 0.82) compared with those in the lowest decile. Greater IRR of hip fracture was predicted for persons living in areas with a greater percent of non-English speakers (IRR 1.004, 95% CI 1.003 to 1.005)., Conclusions: Low income and language fluency are predictors of greater hip fracture incidence. Although much attention is given to the aging of the "baby boomers", low income and immigrant populations are at increased risk for hip fracture and require intervention.

A common operation for patients with complicated sigmoid diverticulitis is resection and placement of an ostomy (Hartmann procedure). This population-based study examines that proportion of ostomates who undergo reversal. In the California inpatient file, patients admitted for acute diverticulitis in 1995 were identified, including a subset that had surgical resection. Data regarding receipt of ostomy were obtained (4-year follow-up). Demographics and clinical data (procedure, ostomy reversal, time to reversal, comorbidity score, and complications) were collected. In 1995, 11,582 admissions for diverticulitis occurred in California. Of these, 24.2 per cent (n = 2808) underwent surgery at admission; 88.9 per cent were sigmoid/left colectomies; and 41.7 per cent had a Hartmann procedure. Patients with ostomies were older (P = 0.0004) and male (P = 0.03). Median comobidity score was the same for patients with or without an ostomy. Of the 1176 patients who had the Hartmann procedure, 65 per cent underwent reversal (mean 143 days). A larger proportion of men than women had their ostomies reversed (74.5% vs 55.9%, respectively, P < 0.0001). Median comorbidity scores for both groups were low, 0 for those reversed and 1 for nonreversed. Our study shows that although the majority of patients had their ostomies reversed, over 35 per cent did not at 4-year follow-up. Further studies are required to evaluate how this rate may be improved.

Virtually all volume-outcome studies use mortality as their outcome measure, yet most general surgical procedures have low in-patient death rates. We examined whether hospital surgical volume impacts other colorectal cancer resection outcomes and complications. Colorectal cancer (CRC) resections from 1996 to 2000 were identified using the California hospital discharge database. Comorbidity was graded using a modified Charlson index. Hospital CRC resection volume was calculated. Serious medical complications were defined as life-threatening cardiac or respiratory events, renal failure, or shock. Serious surgical complications were defined as vascular events, need for reoperation, or bleeding. Multivariate logistic regression analyses were performed to estimate the impact of predictors on complications. We identified 56,621 resections. Median age was 70 to 74 years. Eighty-one per cent of patients were white. Most had localized (57%) versus distant (22%) disease. Serious medical (17.5%) and surgical (9.8%) complications were not infrequent. In multivariate analyses, greater annual CRC surgical volume predicted lower odds of serious complication, but patient characteristics (age, comorbidity, and acuity of surgery) were more important. Although patients receiving CRC resection at lower-volume hospitals have greater odds of complication than patients treated at higher-volume institutions, patient factors remain the most important determinants of complication.

Between 1991 and 2000, the prevalence of obesity increased 65 per cent. As a result, increasing research is being directed at gastric bypass (GB) surgery, an operation that appears to achieve long-term weight reduction. Despite the rapid proliferation of this surgery, the quality of care at a population level is largely unknown. This study examines longitudinal trends in quality and identifies significant predictors of adverse outcomes. Using the California inpatient discharge database, all GB operations from 1996 to 2000 were identified. Demographic, comorbidity, complication, and volume data were obtained. Complications were defined as life-threatening cardiac, respiratory, or medical (renal failure or shock) events. Comorbidity was graded on a modified Charlson score. Annual hospital volume was categorized into four groups: < 50, 50-99, 100-199, and 200+ cases. Based on these data, we calculated longitudinal trends in complication rate and performed logistic regression to identify predictors of complications. A total of 16,232 patients were included. The average age was 41 years; 84 per cent were female, and 83.5 per cent were white. The complication rate was 10.4 per cent. Between 1996 and 2000, rates of cardiac and respiratory complications decreased while rates of medical complications remained unchanged. Complications were more likely in men [odd ratio (OR) = 1.69 compared to women] and in patients with comorbidities (OR = 1.60 for each additional comorbid disease). Furthermore, when examining the effect of volume, patients at very low (< 50) and low (50-99) volume hospitals were much more likely to have complications (OR = 2.72 and 2.70, respectively) compared to patients at high-volume hospitals (200+), even after controlling for differences in case-mix. The quality of care for obesity surgery has improved between 1996 and 2000. Despite operating on patients with more comorbidity, rates of cardiac and respiratory complications have decreased. Furthermore, this study identifies three independent predictors of complications: gender, comorbidity, and hospital volume. These findings are important initial steps toward improving quality in obesity surgery.

Objectives: To determine the prevalence of hospital web sites, the types of information provided within these sites, and the relationship of information to institutional characteristics., Design: Online search of hospital web sites over a 6-week period in late 1999. Web sites were abstracted for content. Bivariate comparisons were made of hospital profit status and ownership or operation by a multihospital network., Participants: California acute care hospitals and their web sites., Main Outcome Measures: Operation of web sites and web site content., Results: Among 390 California hospitals, 242 (62%) had easily identifiable web sites, 59 (15%) had no web sites, and 89 (23%) had sites identified only after telephone follow-up. Hospitals without sites were more likely not-for-profit, small, rural, or unaffiliated. The presentation of information was inconsistent, although most (93%) provided basic contact information. Many hospitals provided health content information (70%) or mentioned health classes (65%), but few guaranteed the quality of this information. Patient care features (online health profiles, risk identification, e-mail) were infrequent (13%) and rudimentary. Product advertising was frequent (54%) but was often nonhealth-related and unobtrusive. Of the 36% of hospitals that reported information on quality, few of the designated measures were valid and reliable measures of quality. Overall, 21% of hospitals reported accreditation (Joint Commission on Accreditation of Healthcare Organizations) status, and for-profit hospital web sites were more likely to report this accreditation., Conclusion: [corrected] Consumers should be aware of current limitations in using information on hospital web sites. In the future, hospitals may better realize the potential of web sites for the delivery of health care information and patient care.

Objectives: This study identified age-related differences in diagnosis and progression of HIV by analyzing a nationally representative sample of HIV-infected adults under care in the United States., Methods: We compared older (> or = 50 years) and younger participants stratified by race/ethnicity. Regression models controlled for demographic, therapeutic, and clinical factors., Results: Older non-Whites more often had HIV diagnosed when they were ill. Older and younger patients were clinically similar. At baseline, however, older non-Whites had fewer symptoms and were less likely to have AIDS, whereas at follow-up they had a trend toward lower survival., Conclusions: Later HIV diagnosis in non-Whites merits public health attention; clinical progression in this group requires further study.

In this paper, we describe a software system for automated monitoring of free-text data in a medical information system that we call RadTRAC (Radiology Text Report Analyzer and Classifier). RadTRAC uses a medical language processing tool and rules derived from statistical analysis of a database to process free-text chest X-ray (CXR) reports and identify reports that describe new or expanding neoplasms for the purpose of monitoring the follow-up of these patients. To evaluate the RadTRAC system, we examined a set of 470 consecutive radiology reports at the Veterans Administration Medical Center, Palo Alto, CA. We compared RadTRAC classification of CXR reports with retrospective expert classification of the reports and with clinical classification from CXR films as recorded in a logbook while the films were being read. The RadTRAC system had a sensitivity of 90% and a specificity of 82% using the logbook as the gold standard. This was similar to the performance of expert radiologists (sensitivity, 92%; specificity, 90%). We then reviewed the charts, appointment schedule, and subsequent X-ray reports of cases either in the logbook or that were identified by RadTRAC as needing follow-up. Two cases in the logbook could have potentially benefited from an automatic monitoring system to ensure follow-up. RadTRAC identified six confirmed new tumors or new metastatic lesions that were not in the logbook. Six other cases were identified by the RadTRAC system with suspicious X-ray findings that had either no follow-up or no further mention of the X-ray lesion in medical records. This suggests that a reminder system based on the RadTRAC technology would be potentially useful.