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This study analyzes data from New York State's new Cardiac Surgery Reporting System, which contains information about cardiac preoperative risk factors, postoperative complications, and hospital discharge. The purposes of the study were to determine the set of significant clinical risk factors and to identify cardiac surgical centers most likely to have serious quality-of-care problems. Significant risk factors for in-hospital death were age, gender, ejection fraction, previous myocardial infarction, number of open heart operations in previous admissions, diabetes requiring medication, dialysis dependence, disasters (acute structural defect, renal failure, cardiogenic shock, gunshot), unstable angina, intractable congestive heart failure, left main trunk narrowed more than 90%, and type of operation performed. Four of the 28 hospitals had significantly higher mortality rates than expected, given the risk factors of their patients. Subsequent site visits and medical record reviews confirmed that these facilities had high percentages of quality-of-care problems among cases resulting in mortality. [ABSTRACT FROM AUTHOR]

We examined the Acute Myocardial Infarction (AMI) incidence and mortality rates in New York State for a recent 13-year period. Hospital discharge data and death certificate information are combined to create patient episodes for AMI. Trends in the risk-adjusted AMI incidence and mortality are examined for the years 1996 through 2008. Between 1996 and 2008, the AMI incidence rate declined by 35.8% and AMI mortality fell from 161.0 to 71.6 per 100,000 population. This 55.5% decline in mortality is accompanied by a 23.9% decline in the number of AMI admissions to acute care hospitals and by a 37.8% improvement in mortality among those hospitalized. New York State follows the national trend in decline in AMI. That decline is accompanied by reductions in AMI mortality, reduced demand on hospitals, and significant improvement in hospital care quality among AMI patients.

Objective: Identify clinical and nonclinical factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents., Methods: Residents (n=26,746) of 147 randomly selected nursing homes in New York State. Data included sociodemographics and clinical and nonclinical related factors. Multivariate linear regression quantified the association between potential determinants and ACS hospitalization., Results: Four factors significantly associated with reduction in ACS hospitalization included nursing staff trained to communicate effectively with physicians regarding a resident's condition (P < .0001), physicians treat residents within the nursing home and admit to hospital as a last resort (P < .0001), provide better information and support to nurses and aides surrounding end-of-life care (P < .0001), and easy access to stat lab results in <4 hours on weekends (P < .0001). Two factors significantly associated with increased ACS hospitalization are: perceived likelihood illness will cause death (P < .0001) and perceived inadequate access to medical history/lab/EKGs (P < .0001)., Conclusion: Preventable ACS hospitalization reduction depends on effective communication between physicians and nursing staff, providing physicians with easy access to stat results in <4 hours on weekends, and easy access to medical records/lab/EKGs. Use of electronic medical records and providing training to nursing staff on how to communicate effectively with physicians and how to articulate about a resident's condition may minimize preventable ACS hospitalizations., (Copyright © 2011 American Medical Directors Association. All rights reserved.)

Objective: To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time., Design: Observation of clinically risk-adjusted operative mortality over time., Setting: All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992., Patients: All 57,187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals., Main Outcome Measures: Actual, expected, and risk-adjusted mortality., Results: Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons (< or = 50 operations per year) experienced a 60% reduction in risk-adjusted mortality in the 4-year period, whereas the highest-volume surgeons (> 150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease., Conclusions: The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).

Objective: To assess changes in outcomes of coronary artery bypass graft (CABG) surgery in New York since 1989, when the State Department of Health began collecting, analyzing, and disseminating information regarding risk factors, mortality, and complications of CABG surgery. These new data stimulated specific quality improvement activities at hospitals throughout the state., Design: A clinical database was used to identify significant independent risk factors and to assess risk-adjusted provider mortality rates., Setting: All 30 hospitals performing CABG surgery in New York during the period 1989 through 1992., Patients: All 57,187 patients undergoing isolated CABG surgery who were discharged from New York State hospitals in 1989 through 1992., Main Outcome Measures: Actual, expected (from a logistic regression model), and risk-adjusted in-hospital mortality., Results: Actual mortality decreased from 3.52% in 1989 to 2.78% in 1992. Because average patient severity of illness increased, risk-adjusted mortality decreased even more--a decrease of 41% from 4.17% in 1989 to 2.45% in 1992. The risk-adjustment model performed well; there were no clinically or statistically significant differences between actual and predicted numbers of deaths at any of 10 levels of patient severity., Conclusions: We believe that this quality improvement program, based on the collection and dissemination of risk-adjusted mortality data for CABG surgery, played a significant role in the observed decline in the death rate from this procedure. Quality improvement programs based on similar principles for other procedures and conditions should be undertaken.

This study uses New York State hospital discharge data to examine the relationship between in-hospital mortality for a patient receiving an abdominal aortic aneurysm resection and the volume of aneurysm operations performed in the previous year at the hospital where the operation took place and by the surgeon performing the operation. Previous research on this topic is extended in several respects: (1) A three-year data base is used to examine the manner in which hospital and surgeon volume jointly affect mortality rate and to examine ruptured and unruptured aneurysms separately; (2) a six-year data base is used to study the "practice makes perfect" hypothesis and the "selective referral" hypothesis; and (3) the degree of specialization of high-volume surgeons is contrasted with that of other surgeons. The results demonstrate a significant inverse relationship between hospital volume and mortality rate for unruptured aneurysms. Further, very few surgeons substantially increased their aneurysm surgery volumes in the six-year study period. Weak selective referral effects were found for both surgeons and hospitals, and higher-volume aneurysm surgeons tended to have much higher specialization rates.

This study uses a new database containing clinical risk factors for cardiac surgery to investigate the relationship between surgical volume (hospital and surgeon) and inhospital mortality rate for all patients receiving coronary artery bypass surgery in New York State in 1989. Also, hospitals with significantly higher and lower mortality rates than expected on the basis of patient preoperative risk factors are identified. The results demonstrate that both annual surgeon volume and annual hospital volume are significantly (inversely) related to mortality rate. The 36% of all coronary bypass operations performed in hospitals with annual bypass volumes of 700 or more by surgeons with annual bypass volumes of 180 or more had a risk-adjusted mortality rate of 2.67% in comparison to a risk-adjusted mortality rate of 4.29% for other bypass operations. Furthermore, low surgical volumes were a major contributor to the outlier status of four of the five hospitals with significantly higher mortality rates than expected.

We tested the efficacy of selected case characteristics in targeting quality of care problems for medical record review. The case characteristics, all of which apply to patients who die in a hospital, consist primarily of procedures and DRGs (diagnosis-related groups) for which death rarely occurs, and a set of complications of surgical care. All characteristics are obtainable from combinations of the principal and secondary diagnoses and procedures in the case, and are available from discharge abstracts. The presence of a quality of care problem is confirmed through a review of the medical record by a nurse and two or more physicians. A logistic regression model that controls for various patient and hospital variables is used as a measure of each of the proposed case characteristics. The results indicate that most of the characteristics are associated with higher percentages of quality of care problems than cases chosen at random, and that the methodology has promise as a tool for targeting cases for medical record review.

Recent studies have demonstrated that the number of times a hospital or surgeon performs certain procedures annually has an inverse relationship with in-hospital mortality rates for patients undergoing the procedures. This study uses an improved measure of physician volume to test the combined relationship of hospital and physician volume with in-hospital mortality rates and to explore the existence of threshold volumes that optimally discriminate high- and low-volume providers. Five procedure groups have significant volume-mortality relationships. For total cholecystectomies, hospital volume is the more significant volume measure, but physician volume is marginally related to mortality rate. For coronary artery bypass surgeries, resection of abdominal aortic aneurysms, partial gastrectomies, and colectomies, physician volume is more significant than hospital volume, but hospital volume is marginally significant. Annual hospital volume thresholds for these data appear to exist at approximately 5 procedures for partial gastrectomies, 40 procedures for colectomies, and 170 procedures for total cholecystectomies.