Archives for April 2016


Measuring Quality in Light of DNRs

By cgallen April 28th, 2016

Original Article:

Skipping adjustment calculations for do-not-resuscitate (DNR) rates at hospitals, or omitting DNR rates altogether, may have skewed hospital quality scores, and could gloss over potentially high-quality decision-making or negligent medical practices, researchers reported.
Without accounting for DNR status, it looked like hospitals with higher rates of patients with DNR orders also had increased mortality rates (adjusted odds ratio 1.17, 95% CI 1.04-1.32); however, if DNR rate adjustments were made, hospitals with higher DNR rates had lower mortality (adjOR 0.79, 95% CI 0.70-0.89), Allan J. Walkey, MD, MSc, of Boston University School of Medicine, and colleagues, reported in JAMA Internal Medicine.

“Although the results of this study are relatively straightforward, the interpretation and implications are anything but,” Leora I. Horwitz, MD, MHS, of NYU School of Medicine, wrote in an accompanying editorial.
“Other studies have shown that DNR patients have higher mortality at all levels of severity of illness, which in theory should not be the case since DNR status should be relevant only in catastrophic situations,” Horwitz wrote. “Therefore, either excluding patients with early DNR status from quality measures or risk adjustment for DNR status has the potential to obscure a tendency by hospitals to provide a lower standard of care for such patients even if that was not the patient’s explicit desire.”
Horwitz noted that there is no easy resolution to this conundrum. With the data that currently exists, it’s not possible to disentangle whether the increased mortality rates among DNR patients and the increased mortality rates at hospitals with more DNR patients reflects the careful attention paid to patient wishes for less aggressive care, or deaths that resulted from a “failure to rescue.”
Horwitz argued that the current state of data reporting and collection has made it impossible to determine whether there actually is an increase in mortality for DNR patients, and increased mortality rates in hospitals with more of these patients. And this has substantial policy implications, for both the current system and any potential changes to the system.
“Qualitative studies might help, as might a more data-driven and patient-centered approach to DNR discussions,” Horwitz wrote. “Accounting for DNR status is likely to encourage the health care system to pursue less-aggressive care for frail elderly patients, which may be more patient-centered and improve quality of life but is also likely to result in some degree of excess mortality for DNR patients. However, continuing the status quo incentivizes a more-aggressive overall approach to care, potentially saving some lives but also potentially causing some patients to undergo more interventions than they might otherwise have chosen,” Horwitz wrote.

Walkey’s team looked at the Project California Sate Inpatient Database, which has a unique, and validated, feature to capture DNR orders that have been written within the first 24 hours of hospitalization. Out of the 90,644 adult pneumonia patients treated across 303 California hospitals in 2011, roughly 5% were admitted. Patients were 52% women, 59% white, and an average age of 73.
Previous research has shown that early DNR orders strongly predict in-hospital and post-hospitalization mortality, according to the authors. Walkey’s group used a random DNR slope model to account for between-hospital variation in associations between hospital DNR and hospital mortality rates, and to diminish potential variation from hospitals that elect to introduce DNR orders at lower levels of illness severity compared with other hospitals. The researchers split the cohort into quartiles. The median early DNR rate was 16% (interquartile range 9%-22%). The proportion of between-hospital variation for DNR orders unexplained by measured clinical covariates was 21% (95% CI 19%-25%). Overall, patients who had DNR orders had a higher risk of mortality compared with patients who did not have DNR orders (adjOR 3.74, 95% CI 3.55-3.93).

Without accounting for DNR status, higher hospital DNR rates were associated with increased patient mortality (adjOR 1.17, 95% CI 1.04-1.32). However, after adjustments for DNR rates, and between-hospital variation in the association between DNR status and mortality rates, hospitals with higher DNR rates had lower mortality (adjOR 0.79, 95% CI 0.70-0.89). And out of the 27 hospitals in the high-mortality quartile, only 14 of these remained outlier after DNR status adjustments were calculated.
Without accounting for patient DNR status, hospitals with higher DNR rates appeared to be associated with lower survival, resulting in hospitals with higher DNR rates receiving worse mortality quality rankings, but after risk adjustments for patient DNR status, hospitals with higher DNR rates demonstrated better survival scores, the authors wrote.
Walkey and colleagues proposed that current methods of comparing hospitals, which do not account for patient DNR status, penalize potentially high-quality hospitals that admit a larger proportion of patients who had chosen to forego resuscitation. “Therefore, accounting for DNR status in programs that compare hospital mortality outcomes may substantially affect publicly reportable hospital rankings and hospital reimbursements.”

The authors reported limitations to the analysis, including potential misclassification bias in the data set, and its restriction to hospitals in California.


SPH and Med Launch New Center

By cgallen April 26th, 2016

Originally published at the BU School of Public Health.

The Schools of Medicine and Public Health are pooling two specific disciplines at a new center to help improve healthcare systems.

The Department of Medicine Center for Implementation and Improvement Sciences (CIIS) will be a methodological hub for the scientific evaluation of current efforts. CIIS will focus on care for underserved populations, particularly at Boston Medical Center.

Mari-Lynn Drainoni, associate professor of health law, policy & management at SPH, will serve as co-director of CIIS and will lead the implementation science component. The quality improvement component will be led by Allan Walkey, assistant professor of medicine at MED.

“I’m excited about bringing more of an implementation science focus to the campus, especially this that is more safety-net focused,” says Drainoni.

Implementation science looks at how and whether new evidence-based endeavors are put into clinical practice, while improvement science measures outcomes of these efforts to improve healthcare delivery. CIIS will allow researchers, clinicians, and administrators to pool their methods and knowledge from these two disciplines, guiding, supporting, and innovating design of projects evaluating efforts to implement healthcare system change.

The center will also educate faculty and trainees in implementation and improvement sciences with short training programs.

Michelle Samuels


New Health Care Center to Bridge Gap Between Medical Improvement, Implementation

By cgallen April 19th, 2016

The Boston University School of Medicine and BU School of Public Health launched the Center for Implementation and Improvement Sciences Friday, according to a BUSM release. Administered under the BUSM’s Department of Medicine, the new center will provide research facilities for clinicians, administrators and health services researchers to focus on healthcare delivery for underserved populations, the release stated.

CIIS co-director Allan Walkey said the key to a successful healthcare center is not solely system improvement, but also the ability to rigorously and scientifically document the outcome. Walkey, a professor of medicine at BUSM, said he will work to improve the scientific element in the center.

“A lot of men and women put a lot of effort and work trying to improve care, but it’s just unclear after they do that whether there is something changed as a result of that,” Walkey said. “So really the point is to try to better learn from those attempts, to structure them in such a way that we can see if these attempts resulted in intended ways.”

Mari-Lynn Drainoni, fellow co-director of CIIS and a professor of health law, policy and management in SPH, said she plans to lead the implementation science component of the center.

“I’m excited about bringing more of an implementation science focus to the campus, especially this that is more safety-net focused,” Drainoni said in the release.

Combining implementation and improvement sciences together, Chairman of the Department of Medicine David Coleman said, CIIS is dedicated to improving hospital care through scientific methodology.

“Quality improvement sciences is how we improve the process of care in hospitals to achieve better outcome, and implementation sciences studies change, change management and the determinants of successful changes and sustainable change,” Coleman said. “The idea is to design projects that would ultimately and effectively implement change in healthcare systems with a safety net that protects vulnerable patient populations.”

CIIS will also provide effective methodical assistance to evaluate and monitor successful attempts to improve healthcare quality, Coleman said. He and his team have been planning the establishment of the center for more than a year, he said.

“We met with people in the two fields. We realized there are some wonderful people in the implementation sciences and wonderful people in improvement sciences,” Coleman said. “We thought if we put the center together, we might accelerate that marriage of these two fields.”

Coleman said the center aims to increase communication between implementation and improvement sciences and educate faculty and students on the two disciplines.

“We want to train medical students, doctors, nurses, social workers, healthcare administrators, public health students, so we have a pretty big agenda ultimately.” Coleman said. “The first year will be a lot of education, [creating] interest groups in seminar series and some pilot programs that combine the two field.”

Several students who study on BU’s Medical Campus said they are greatly interested in the new center, saying it will bring new air to the medical work field.

Shawn Zajicek, a second-year graduate student in the Sargent College of Health and Rehabilitation Sciences and SPH, said the center allows researchers and faculty members to push for scientific improvement.

“One issue is that clinicians learned something so long ago, and wouldn’t change or accept new ideas that have been found through science,” Zajicek said. “The new center can help doctors to stay updated to the new methodology.”

Kerrin Gallagher, a senior in Sargent, said the center might be a barrier for practicality due to a larger theoretical and conceptual presence.

“Sometimes [a new method] sounds good on paper, but sometimes it’s really hard to get the evidence-based kind of thing into actual practice and get patients behind it,” Gallagher said. “But [the center] seems like a really cool concept.”