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Background: The role of hospital factors in the decision to transfer acute ischemic stroke (AIS) patients is not clear. Objective: To determine whether hospital quality is associated with the transfer of stroke patients between 2 hospitals. Methods: Medicare claims data were used to identify AIS patients transferred between hospitals in the Northeast US from 2007-2011. We categorized hospitals as transferring hospitals (TH), retaining hospitals (RH), and accepting hospitals (AH) based on the largest proportion of AIS patient encounters that were transferred, retained, or accepted. All AHs participated in Get With The Guideline (GWTG)-Stroke, enabling the use of registry data to determine hospital performance by tPA use, composite quality measure score and door-to-needle (DTN) time for tPA. We identified connected TH-AH dyads as those with > 5 patients transferred annually and used logistic regression to identify hospital characteristics associated with the establishment of a given TH-AH connection. We fitted separate models for each measure of performance (rate of tPA use, GWTG composite quality measure and median DTN time); we also adjusted for driving distance between hospitals, AH stroke volume, and the number of hospitals in the AH’s referral region. Results: Of 394 Northeast hospitals, there were 136 THs, 241 RHs, and 17 AHs. The odds of an establishing an AH-TH connected dyad were influenced by many factors and increased when quality measure performance increased at the AH or decreased at the TH (Table). Conclusion: Among Northeast U.S. hospitals, we found that interfacility transfer destinations of choice were sensitive to differences in AH quality, with higher AH performance associated with increased likelihood of being a transfer destination. Further research is needed to better understand AIS transfer patterns in order to optimize the transfer system for maximal patient benefit in the future.

Background— Candidates for cardiac resynchronization therapy (CRT) receive either a biventricular pacemaker or a biventricular pacemaker with an implantable cardioverter-defibrillator (CRT-D). Optimal device selection remains challenging because the benefit of implantable cardioverter-defibrillator therapy may not be uniform, particularly in patients at competing risk of nonsudden death. Methods and Results— In this serial cross-sectional study using the National Inpatient Sample database, we identified 311 086 admissions associated with CRT implant between 2006 to 2012. CRT-D was the most common device type (86.1%), including in patients ≥75 years of age with ≥5 Elixhauser comorbidities (75.5%). Multivariate predictors of CRT-D implant included demographic, clinical, and geographic factors: prior ventricular arrhythmia (rate ratio [RR], 1.14; 95% CI, 1.13–1.14), ischemic heart disease (RR, 1.11; 95% CI, 1.10–1.11), male sex (RR, 1.10; 95% CI, 1.09–1.10), black race (RR, 1.06; 95% CI: 1.04–1.07), and Northeast geographic region (RR, 1.06; 95% CI, 1.04–1.09). There was significant interhospital variation in the use of CRT-D (10–90 percentile range, 72.9%–98.0% CRT-D). Conclusions— The majority of patients in this contemporary US cohort underwent implantation of CRT-D. Predictors of CRT-D implant included demographic, clinical, and geographic factors. In patient subgroups predicted to have an attenuated benefit from implantable cardioverter-defibrillator therapy (older adults with multiple comorbidities), CRT-D remained the dominant device type. An improved understanding of the determinants of device selection may aid in decision making and ultimately better align patient risk with device benefit at the time of CRT implantation.

Introduction: Little is known about how hospitals are connected in the care of patients with acute ischemic stroke (IS). We aimed to describe changes over time in the IS interfacility transfer network in the Northeastern U.S. Methods: We used data from inpatient and outpatient Medicare claims in the Northeast region to identify IS patients transferred between hospitals from 2007 to 2011. Receiving hospitals (RHs) were defined as hospitals with annual IS volume of at least 120 admissions and ≥15% of these admissions received as transfers. Transferring hospitals (THs) were defined as non-RHs that transferred ≥15% of total (ED plus inpatient) IS discharges. A connection between hospitals was defined as ≥5 patients/year transferred between any given TH and RH in the region. We generated a map of hospital connections for each year during the study period using ArcGIS 10.3.1. Results: Among 130,338 IS admissions, we identified 6,898 (5%) patient transfers in the Northeast region from 2007-2011. The number of patients transferred increased from 960 (4%) in 2007 to 1772 (7%) in 2011 (p for trend Conclusion: From 2007 to 2011, hospitals in the U.S. Northeast became more connected in the care of IS patients, with a growing number of connections between hospitals. Yet, by our definition, the majority of hospitals remained unconnected, potentially representing a missed opportunity. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.

Many health care organizations seek physicians to lead quality improvement (QI) efforts, yet struggle to find individuals with the necessary expertise. Although most residency programs incorporate QI and patient safety principles into their curricula, few provide a specialized training program for residents exploring careers as physician leaders in quality.Recognizing this training void, the authors designed and implemented the Healthcare Leadership in Quality (HLQ) track for residents at the University of Pennsylvania Health System in 2010. This longitudinal, two-year graduate medical education (GME) track aligns with the quality goals of the University of Pennsylvania Health System and includes a core curriculum, integration into an interprofessional health care leadership team that is accountable for quality and safety outcomes on a hospital unit, a capstone QI project, and mentorship.Early evaluation has demonstrated the feasibility and efficacy of the track diverse graduate medical education training programs. Using Yardley and Dornan's interpretation of the Kirkpatrick framework, the authors have demonstrated the track's impact on four levels of educational and organizational outcomes.Building on their early experiences, the authors are integrating project and time management skills into the core curriculum, and they are focusing more effort on faculty development in QI mentorship. Additionally, the authors plan to follow HLQ track graduates to determine whether they seek leadership roles in quality and safety and to assess the influence of the program on their careers.

We examined trends in health insurance coverage among 36,999 HIV-infected adults in care at 11 US HIV clinics between 2006 and 2012. Aggregate health insurance coverage was stable during this time. The proportions of patient-years with private, Medicaid, Medicare, and no insurance during this period were 15.9%, 35.7%, 20.1%, and 28.4%, respectively. Medicaid coverage was more prevalent among women than men, blacks, and Hispanics than whites, and individuals with injection drug use risk compared with other transmission risk factors. Hispanics and younger age groups were more likely to be uninsured than other racial/ethnic and older age groups, respectively.

To develop prediction rules to identify which women with preterm labor are at greatest risk for delivery within 10 days and before 37 weeks of gestation using demographic and clinical risk factors alone.We analyzed data collected for a prospective cohort study of singleton pregnancies at 22-33 6/7 weeks of gestation with preterm labor. Potential risk factors were included in multivariable logistic models for each outcome. Using backwards regression, we identified combinations of risk factors that generated the most parsimonious yet predictive models. Adjusted odds ratios of covariates in the final models were used to estimate weights for each risk factor and were summed to generate a predictive score. The score associated with the highest negative predictive value was defined as a positive test result for each outcome. Bootstrapping techniques internally validated the scoring systems.We include data from 583 women. The risk of delivery within 10 days was 15.4% (n=90) and before 37 weeks of gestation it was 35.0% (n=204). The final model for delivery within 10 days included initial cervical dilatation, no prenatal care, and tobacco use (area under curve=0.75), and for delivery before 37 weeks of gestation it included initial cervical dilatation, obstetric history, and tobacco use (area under the curve=0.73). A positive test result was associated with 84% sensitivity, 51% specificity, 24% positive predictive value, and 95% negative predictive value in predicting delivery within 10 days and 79% sensitivity, 50% specificity, 46% positive predictive value, and 82% negative predictive value in predicting delivery before 37 weeks of gestation.Based on their strong negative predictive values, these prediction rules could identify patients who do not require intensive monitoring when they present with preterm labor.II.

Background Blood cultures are frequently obtained in the emergency department (ED) evaluation of children with community-acquired pneumonia (CAP). Objectives To determine the prevalence of bacteremia in children presenting to the ED with CAP, identify subgroups at increased risk for bacteremia, and quantify the effect of positive blood cultures on management. Methods This case-control study was nested within a cohort of children followed up at 35 pediatric practices. Patients from this cohort who were ≤18 years of age, evaluated in the ED in 2006-2007, and diagnosed with CAP were eligible. Cases were those with bacteremia. Controls included those with negative blood cultures and those without blood cultures performed. Results A total of 877 (9.6%) of 9099 children with CAP were evaluated in the ED. The mean age was 3.6 years; 53% were male. Blood cultures were obtained from 291 children (33.2%). Overall, the prevalence of bacteremia was 2.1% (95% confidence interval [CI]: 0.8%-4.4%). Bacteremia occurred in 2.6% (95% CI: 1.0%-5.6%) with an infiltrate on chest radiograph and in 13.0% (95% CI: 2.8%-33.6%) with complicated pneumonia. Streptococcus pneumoniae accounted for 4 of the 6 cases of bacteremia. Blood culture results altered management in 5 of the 6 bacteremic patients; 1 had an appropriate broadening and 4 had an appropriate narrowing of coverage. The contamination rate was 1.0% (95% CI: 0.2%-3.0%). Conclusion Children presenting to the ED for evaluation of CAP are at low-risk for bacteremia. Although positive blood cultures frequently altered clinical management, the overall impact was small because of the low prevalence of bacteremia.