Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery.
The ...authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy.
Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 6.8% vs. 1,040 8.1%, P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures.
Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.
IMPORTANCE: More than 300 000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. OBJECTIVE: To ...test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. DESIGN, SETTING, AND PATIENTS: We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. EXPOSURES: Spinal or epidural anesthesia; general anesthesia. MAIN OUTCOMES AND MEASURES: Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. RESULTS: Of 56 729 patients, 15 904 (28%) received regional anesthesia and 40 825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21 514 patients included in this match: 583 of 10 757 matched patients (5.4%) who lived near a regional anesthesia–specialized hospital died vs 629 of 10 757 matched patients (5.8%) who lived near a general anesthesia–specialized hospital (instrumental variable estimate of risk difference, −1.1%; 95% CI, −2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, −0.8 to −0.4, P < .001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis. CONCLUSIONS AND RELEVANCE: Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.
IMPORTANCE: Little is known regarding outcomes after hip fracture among long-term nursing home residents. OBJECTIVE: To describe patterns and predictors of mortality and functional decline in ...activities of daily living (ADLs) among nursing home residents after hip fracture. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 60 111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. MAIN OUTCOMES AND MEASURES: Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. RESULTS: Of 60 111 patients, 21 766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio HR, 2.17; 95% CI, 2.09-2.26 P < .001), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 P < .001), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 P < .001). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk RR, 1.66; 95% CI, 1.56-1.77 P < .001), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 P < .001), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 P < .001). CONCLUSIONS AND RELEVANCE: Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.
Internal medicine residency programs were randomly assigned to standard duty-hour policies or to flexible policies without limits on shift length and time off. Interns in programs with flexible ...policies did not have a superior educational experience.
Objective. To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.
Data Sources. Secondary analysis of cancer registry, inpatient ...claims, administrative and nurse survey data collected in Pennsylvania for 1998–1999.
Study Design. Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30‐day mortality, complications, and failure to rescue (death following a complication).
Principal Findings. Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07–1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07–2.03). Receipt of care in National Cancer Institute‐designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.
Conclusions. This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.
Every newly trained surgeon performs her first unsupervised operation. How do the health outcomes of her patients compare with the patients of experienced surgeons? Using data from 498 hospitals, we ...compare 1252 pairs comprised of a new surgeon and an experienced surgeon working at the same hospital. We introduce a new form of matching that matches patients of each new surgeon to patients of an otherwise similar experienced surgeon at the same hospital, perfectly balancing 176 surgical procedures and closely balancing a total of 2.9 million categories of patients; additionally, the individual patient pairs are as close as possible. A new goal for matching is introduced, called "refined covariate balance," in which a sequence of nested, ever more refined, nominal covariates is balanced as closely as possible, emphasizing the first or coarsest covariate in that sequence. A new algorithm for matching is proposed and the main new results prove that the algorithm finds the closest match in terms of the total within-pair covariate distances among all matches that achieve refined covariate balance. Unlike previous approaches to forcing balance on covariates, the new algorithm creates multiple paths to a match in a network, where paths that introduce imbalances are penalized and hence avoided to the extent possible. The algorithm exploits a sparse network to quickly optimize a match that is about two orders of magnitude larger than is typical in statistical matching problems, thereby permitting much more extensive use of fine and near-fine balance constraints. The match was constructed in a few minutes using a network optimization algorithm implemented in R. An R package called rcbalance implementing the method is available from CRAN.
We propose new optimal matching techniques for large administrative data sets. In current practice, very large matched samples are constructed by subdividing the population and solving a series of ...smaller problems, for instance, matching men to men and separately matching women to women. Without simplification of some kind, the time required to optimally match 𝑇 treated individuals to 𝑇 controls selected from 𝐶 ≥ 𝑇 potential controls grows much faster than linearly with the number of people to be matched—the required time is of order 𝑂{(𝑇+𝐶)3}—so splitting one large problem into many small problems greatly accelerates the computations. This common practice has several disadvantages that we describe. In its place, we propose a single match, using everyone, that accelerates the computations in a different way. In particular, we use an iterative form of Glover's algorithm for a doubly convex bipartite graph to determine an optimal caliper for the propensity score, radically reducing the number of candidate matches; then we optimally match in a large but much sparser graph. In this graph, a modified form of near-fine balance can be used on a much larger scale, improving its effectiveness. We illustrate the method using data from US Medicaid, matching children receiving surgery at a children's hospital to similar children receiving surgery at a hospital that mostly treats adults. In the example, we form 38,841 matched pairs from 159,527 potential controls, controlling for 29 covariates plus 463 Principal Surgical Procedures, plus 973 Principal Diagnoses. The method is implemented in an R package bigmatch available from CRAN.
CONTEXT The worsening hospital nurse shortage and recent California legislation
mandating minimum hospital patient-to-nurse ratios demand an understanding
of how nurse staffing levels affect patient ...outcomes and nurse retention in
hospital practice. OBJECTIVE To determine the association between the patient-to-nurse ratio and
patient mortality, failure-to-rescue (deaths following complications) among
surgical patients, and factors related to nurse retention. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analyses of linked data from 10 184 staff nurses
surveyed, 232 342 general, orthopedic, and vascular surgery patients
discharged from the hospital between April 1, 1998, and November 30, 1999,
and administrative data from 168 nonfederal adult general hospitals in Pennsylvania. MAIN OUTCOME MEASURES Risk-adjusted patient mortality and failure-to-rescue within 30 days
of admission, and nurse-reported job dissatisfaction and job-related burnout. RESULTS After adjusting for patient and hospital characteristics (size, teaching
status, and technology), each additional patient per nurse was associated
with a 7% (odds ratio OR, 1.07; 95% confidence interval CI, 1.03-1.12)
increase in the likelihood of dying within 30 days of admission and a 7% (OR,
1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After
adjusting for nurse and hospital characteristics, each additional patient
per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase
in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in
the odds of job dissatisfaction. CONCLUSIONS In hospitals with high patient-to-nurse ratios, surgical patients experience
higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses
are more likely to experience burnout and job dissatisfaction.
IMPORTANCE Difference in breast cancer survival by race is a recognized problem among Medicare beneficiaries. OBJECTIVE To determine if racial disparity in breast cancer survival is primarily ...attributable to differences in presentation characteristics at diagnosis or subsequent treatment. DESIGN, SETTING, AND PATIENTS Comparison of 7375 black women 65 years and older diagnosed between 1991 to 2005 and 3 sets of 7375 matched white control patients selected from 99 898 white potential controls, using data for 16 US Surveillance, Epidemiology and End Results (SEER) sites in the SEER-Medicare database. All patients received follow-up through December 31, 2009, and the black case patients were matched to 3 white control populations on demographics (age, year of diagnosis, and SEER site), presentation (demographics variables plus patient comorbid conditions and tumor characteristics such as stage, size, grade, and estrogen receptor status), and treatment (presentation variables plus details of surgery, radiation therapy, and chemotherapy). MAIN OUTCOMES AND MEASURES 5-Year survival. RESULTS The absolute difference in 5-year survival (blacks, 55.9%; whites, 68.8%) was 12.9% (95% CI, 11.5%-14.5%; P < .001) in the demographics match. This difference remained unchanged between 1991 and 2005. After matching on presentation characteristics, the absolute difference in 5-year survival was 4.4% (95% CI, 2.8%-5.8%; P < .001) and was 3.6% (95% CI, 2.3%-4.9%; P < .001) lower for blacks than for whites matched also on treatment. In the presentation match, fewer blacks received treatment (87.4% vs 91.8%; P < .001), time from diagnosis to treatment was longer (29.2 vs 22.8 days; P < .001), use of anthracyclines and taxols was lower (3.7% vs 5.0%; P < .001), and breast-conserving surgery without other treatment was more frequent (8.2% vs 7.3%; P = .04). Nevertheless, differences in survival associated with treatment differences accounted for only 0.81% of the 12.9% survival difference. CONCLUSIONS AND RELEVANCE In the SEER-Medicare database, differences in breast cancer survival between black and white women did not substantially change among women diagnosed between 1991 and 2005. These differences in survival appear primarily related to presentation characteristics at diagnosis rather than treatment differences.
Background
Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The ...value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear.
Objective
To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources.
Design
Matched cohort study of patients in 306 acute care hospitals.
Patients
A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status.
Main Measures
Better (
n
= 76) and worse (
n
= 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs.
Key Results
Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%,
p
< 0.0001) and fewer readmissions (32.3% vs 33.6%,
p
< 0.0001) yet costs were not significantly different ($18,848 vs 18,671,
p
= 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%,
p
< 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost.
Conclusions
Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.
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