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Importance: Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population., Objective: To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period., Design, Setting, and Participants: This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020., Exposure: Race and ethnicity., Main Outcomes and Measures: Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death., Results: Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85)., Conclusions and Relevance: Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Objective: While racial, ethnic, and socioeconomic group disparities in cognitive impairment and dementia prevalence are well-documented among community-dwelling older adults, little is known about these disparity trends among older adults receiving Medicaid-funded home- and community-based services (HCBS) in lieu of nursing home admission. The authors determined how dementia prevalence and cognitive impairment severity compare by race, ethnicity, educational attainment, and neighborhood context in a Medicaid HCBS population., Design/setting: A cross-sectional study in Connecticut., Participants: Adults age ≥65 in the HCBS program, January-March 2019 (N = 3,520)., Measurements: The data source was Connecticut's HCBS program Universal Assessment tool. The authors employed two outcomes: Cognitive Performance Scale (CPS2), a 9-point measure ranging from cognitively intact-very severe impairment; and presence or not of either diagnosed dementia or CPS2 score ≥4 (major impairment). Neighborhood context was measured using the Social Vulnerability Index (SVI)., Results: Cohort characteristics: 75.7% female; mean(SD) age = 79.1(8.2); Non-Hispanic White = 47.8%; Hispanic = 33.6%; Non-Hispanic Black = 15.9%. Covariate-adjusted multivariate analyses revealed no dementia/major impairment prevalence differences among White, Black, and Hispanic individuals, but impairment severity was greater among Hispanic participants (b = 0.22; p = 0.02). People with more than HS education had less severe impairment (b = -0.12; p <0.001) and lower likelihood of dementia/major impairment (AOR = 0.61; p <0.001). Dementia/major impairment likelihood and impairment severity were greater in less socially vulnerable neighborhoods., Conclusion: Racial and ethnic group differences in cognitive impairment are less pronounced in Medicaid-funded HCBS cohorts than in other community-dwelling older adult cohorts. SVI results suggest that, among other possible explanations, older adults with dementia may move to lower social vulnerability neighborhoods where supportive family members reside., (Copyright © 2022 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Following colorectal surgery, venous thromboembolism (VTE) is a serious complication occurring at an estimated incidence of 2-4%. There is a significant body of literature stratifying risk of VTE in specific populations undergoing colorectal resection for cancer or inflammatory bowel disease. There has been little research characterizing patients undergoing colorectal surgery for other indications, e.g. diverticulitis. We hypothesize that there exists a subgroup of patients with identifiable risk factors undergoing resection for diverticulitis that has relatively higher risks for VTE. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Project database from 2006 to 2017 who underwent colorectal resection for diverticulitis. Patients with a primary indication for resection other than diverticulitis were excluded. Multivariate logistic regression modeling was conducted to determine the risk of VTE for each independent variable. A novel scoring system was developed and a receiver-operating-characteristic curve was generated. The rate of VTE was 1.49%. An 7-point scoring system was developed using identified significant variables. Patients scoring ≥ 6 on the developed scoring scale had a 3.12% risk of 30-day VTE development. A simple scoring system based on identified significant risk factors was specifically developed to predict the risk of VTE in patients undergoing diverticular colorectal resection. These patients are at significantly higher risk and may justify increased vigilance regarding VTE events, similar to patients undergoing colorectal resection for cancer or inflammatory bowel disease., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Obesity is a challenging condition to treat in patients with chronic liver disease (CLD). The safety and efficacy of bariatric surgery (BS) in patients with CLD is not well established. The aim of this study is to evaluate outcomes of BS in patients with CLD., Methods: Data from the National Inpatient Sample for 2012-2015, accounting for over 7 million discharges, were analyzed. All patients undergoing BS were identified using ICD-9/CPT codes. Patients were then stratified based on the presence of CLD using ICD-9 codes. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges (THC). Secondary outcomes, including infection, bleeding, improper wound healing, and surgical revision, were identified using ICD-9 codes., Results: A total of 302,306 patients underwent BS, of which 20,095 (6.6%) were diagnosed with CLD. CLD patients had greater inpatient mortality, with adjusted odds ratio of 1.47 (95% CI 1.24-1.73). CLD patients also had greater THC but shorter LOS. CLD patients had significantly less surgical revision, improper wound healing, and postoperative infection. There was no difference in bleeding complications between groups., Conclusion: Inpatient mortality following BS in CLD patients is low; however, there was an increased risk compared with the non-CLD population. Postoperative complications were no different or even less frequent in CLD patients compared with the general population. BS should not be discounted as a treatment option for obesity in patients with CLD.

Background: Inflammatory bowel disease (IBD) entails a higher risk of infections, including those that could be prevented with immunizations. Current Advisory Committee on Immunization Practices and American College of Gastroenterology vaccine recommendations for patients with IBD are based on low levels of evidence., Methods: We conducted a population-based descriptive cohort study using the US National Inpatient Sample ICD-9 codes from 2012 to 2015. We measured the frequency of patients with IBD who were admitted to the hospital with a vaccine-preventable disease (VPD). Frequencies and demographics were determined and compared between patients with IBD and patients without IBD., Results: Of discharges, 596,485 (2.08%) were secondary to a VPD, and 7180 (1.2%) were found to have both a VPD and IBD (including Crohn disease and ulcerative colitis). The most common VPDs among patients with IBD were herpes zoster virus (HZV) (34.9%) and hepatitis B virus (31.6%), followed by influenza (22.1%). Pneumococcal pneumonia (9.1%) and hepatitis A virus (2.4%) were less common. Inpatients with IBD were twice as likely to have HZV when compared to non-IBD inpatients (odds ratios [OR] = 2.30 [95% CI, 2.06-2.58], P < 0.0001) This finding was consistent for every study year. Pneumococcal pneumonia [OR = 0.62 (95% CI, 0.52-0.74), P < 0.0001] and influenza [OR = 0.72 (95% CI, 0.63-0.81), P < 0.0001] were significantly lower in the IBD population. There was no difference for other VPDs., Conclusions: HZV was the most frequent VPD in IBD inpatients. Patients with IBD have a higher rate of hospital admissions with HZV and a lower rate of pneumococcal pneumonia and influenza admissions when compared with non-IBD patients. For other VPDs, patients with IBD have the same rate of admission as the general population., (© 2019 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Monitoring medication administration errors (MAE) is often included as part of the hospital's risk management program. While observation of actual medication administration is the most accurate way to identify errors, hospitals typically rely on voluntary incident reporting processes. Although incident reporting systems are more economical than other methods of error detection, incident reporting can also be a time-consuming process depending on the complexity or "user-friendliness" of the reporting system. Accurate incident reporting systems are also dependent on the ability of the practitioner to: 1) recognize an error has actually occurred; 2) believe the error is significant enough to warrant reporting; and 3) overcome the embarrassment of having committed a MAE and the fear of punishment for reporting a mistake (either one's own or another's mistake).

Over 50 million people in the United States (about 20% of the population) live in rural areas, but only 9% of the nation's physicians practice in rural communities. It is difficult to recruit and retain rural health care practitioners, partly because of issues relating to professional isolation. New and enhanced telecommunications links between community and academic hospitals show promise for reducing this isolation and enhancing lifelong learning opportunities for rural health care providers. This paper will explore some of the issues involved in using interactive video (telemedicine) networks to transmit continuing medical education programming from an academic center to multiple rural hospitals. Data from a recent University of Iowa survey of the state's health educators will be presented as one approach to assessing the health care marketplace for the deployment of tele-education services.

Background: Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates., Methods: Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported., Results: The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs., Conclusions: There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.

Peer review is an essential mechanism for evaluating the judgment and performance of clinical providers. Reasons for conducting physician peer review range from identified quality-of-care concerns to general education. There are a variety of challenges to conducting an effective peer review, including the personal concerns of the peers conducting the reviews. This article reviews the potential uses of physician peer review, its basic methodologies, and challenges to and suggestions for obtaining effective peer review.

Background: Many health care organizations have embraced the philosophy and tools of total quality management (TQM) and continuous quality improvement (CQI) without overt linkage to existing peer review processes. Achieving total quality in an organization requires that both peer review and TQM/CQI improvement processes be effectively used., Examples: Three ways of linking peer review and TQM/CQI include: 1) coordinating TQM/CQI and peer review quality improvement initiatives whenever possible; 2) expanding the focus of peer review to include assessment of the processes and systems within which the clinician functions; and 3) linking peer review and TQM/CQI improvement processes to address behavioral and attitudinal issues having economic roots.

As the federal administration advances the idea of the "information superhighway," many disciplines are being challenged to find ways to use advanced telecommunications to improve access to information, enhance learning opportunities, and achieve higher levels of international competitiveness. Telemedicine, the use of communications technology in the practice of medicine, may change the way rural health care is provided by improving access to medical information, diagnostic tools, and consultations. The information and health care services required by health care professionals are rapidly changing, and dissemination of this information to isolated practitioners has proven to be difficult. By providing support electronically from a central site, the most current information is more readily available. Using test-bed hospitals in rural and urban settings, the National Library of Medicine-funded National Laboratory for the Study of Rural Telemedicine at the University of Iowa is currently developing the necessary infrastructure to support targeted projects studying how telemedicine applications can be made more effective and readily available.

Background: Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences., Discussion: PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries., Conclusion: For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.

A causal model of turnover, or quitting, among hospital nursing department employees was evaluated. This model includes job satisfaction, organizational commitment, and intent to leave as intervening variables that mediate 13 determinants of turnover. The sample consisted of 841 female nursing department employees selected from five hospitals in a western state. Attitudinal and background data were obtained through a mail questionnaire survey, and turnover was monitored for 18 months following the survey. Intent to leave had a strong direct effect on turnover while kinship responsibility, job satisfaction, and organizational commitment had indirect effects on turnover through intent to leave. Task repetitiveness, autonomy, promotional opportunities, and fairness of rewards were important determinants of jobs satisfaction and thus provide a mechanism whereby hospital management may enhance commitment to the organization while reducing turnover.

A survey of 162 Veterans Administration Medical Center (VAMC) laboratories performing antimicrobial susceptibility testing was performed to determine variation in reported rates of methicillin-resistant Staphylococcus aureus (MRSA) isolation by geographic location and hospital characteristics. Of the 162 VAMC laboratories surveyed, 136 (84%) provided usable data. The percentage of S aureus isolates reported as resistant to methicillin ranged from 0% to 52% with a mean value of 10% among the 136 survey respondents. MRSA were isolated in every VA Medical District and 96% of all respondent laboratories reported isolating at least one MRSA isolate during the preceding year. These data are considered an underestimate of the time MRSA rate in the VA system due to the fact that many laboratories failed to follow key methodologic guidelines for optimal detection of MRSA. A positive correlation was found between MRSA isolation rate and several measures of hospital size and activity including total beds, total admissions, and total antimicrobial susceptibility tests performed. Geographic clustering of MRSA isolation was observed with distinct areas of very high and very low percentages of S aureus isolates reported as MRSA. The data suggest that the geographic distribution of MRSA within the VA system should be monitored closely for evidence of spread from areas with high-MRSA rates to areas of mid- or low-MRSA rates. Evidence of increased MRSA isolation within these areas may necessitate increased caution in patient referral and transfer patterns within the VA system.

Existing methods for estimating additional days of hospital stay due to nosocomial infections (NI) have a number of documented limitations. An alternative method described in this paper uses the Appropriateness Evaluation Protocol (AEP) to determine whether each day of acute inpatient care is appropriate based on the need for care of the NI, original cause of hospitalization (OC), or combined NI-OC requirements. Using this method to identify specific days of hospitalization due to Staphylococcus aureus nosocomial infection, we find: 1) length of stay is increased for only a minority of patients (38%); 2) an average of 20 additional days of stay occurred for patients with 1 or more days attributed to NI; and 3) an average of 52% of length of stay of patients with 1 or more days attributed to NI can be attributed to the NI. Application of the AEP-based method is a useful alternative for identifying additional days of stay due to NI.