(Press-News.org) CHICAGO – Adding stroke severity to a hospital 30-day mortality model based on claims data for Medicare beneficiaries with acute ischemic stroke was associated with improvement in predicting the risk of death at 30 days and changes in performance ranking regarding mortality for a considerable proportion of hospitals, according to a study in the July 18 issue of JAMA.
"Increasing attention has been given to defining the quality and value of health care through reporting of process and outcome measures. National quality profiling efforts have begun to report hospital-level performance for Medicare beneficiaries, including 30-day mortality rates, for common medical conditions, including acute myocardial infarction [heart attack], heart failure, and community-acquired pneumonia," according to background information in the article. Stroke is among the leading causes of death, disability, hospitalizations, and health care expenditures in the United States. "There is increasing interest in reporting risk-standardized outcomes for Medicare beneficiaries hospitalized with acute ischemic stroke, but whether it is necessary to include adjustment for initial stroke severity has not been well studied."
Gregg C. Fonarow, M.D., of the University of California, Los Angeles, and colleagues conducted a study to evaluate the degree to which hospital outcome ratings and the ability to predict 30-day mortality are altered after including initial stroke severity in a claims-based risk model for hospital 30-day mortality for acute ischemic stroke. For the study, data were analyzed from 782 Get With The Guidelines-Stroke participating hospitals on 127,950 fee-for-service Medicare beneficiaries with ischemic stroke. The patients had a score documented for the National Institutes of Health Stroke Scale (NIHSS, a 15-item neurological examination scale with scores from 0 to 42, with higher scores indicating more severe stroke) between April 2003 and December 2009. The median (midpoint) age was 80 years, 57 percent were women, and 86 percent were white. Performance of claims-based hospital mortality risk models with and without inclusion of NIHSS scores for 30-day mortality was evaluated and hospital rankings from both models were compared. The NIHSS median score in this overall population was 5, and the median hospital-level NIHSS score was 5.
There were 18,186 deaths (14.5 percent) within the first 30 days, including 7,430 deaths during the index hospitalization (in-hospital mortality, 5.8 percent). The median hospital-level 30-day mortality rate was 14.5 percent. The researchers found that the hospital mortality model with NIHSS scores had significantly better discrimination than the model without. Also, other index scores demonstrated substantially more accurate classification of hospital 30-day mortality after the addition of NIHSS score to the claims model. The model with NIHSS exhibited better agreement between observed and predicted mortality rates.
Analysis of data indicated that more than 40 percent of hospitals identified in the top or bottom 5 percent of hospital risk-adjusted mortality would have been reclassified into the middle mortality range using a model adjusting for NIHSS score compared with a model without NIHSS score adjustment. "Similarly, when considering the top 20 percent and bottom 20 percent ranked hospitals, close to one-third of hospitals would have been reclassified," the authors write.
"These findings highlight the importance of including a valid specific measure of stroke severity in hospital risk models for mortality after acute ischemic stroke for Medicare beneficiaries. Furthermore, this study suggests that inclusion of admission stroke severity may be essential for optimal ranking of hospital with respect to 30-day mortality."
"As public reporting and value-based purchasing policies increase for outcome measures, it is important to recognize the effect that using models with less than ideal discrimination and calibration has on the ranking of hospitals and the lack of correlation among ranking by models that do and do not adjust for critical risk determinants," the researchers write.
(JAMA. 2012;308[3]:257-264. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Comparing Hospitals on Stroke Care - The Need to Account for Stroke Severity
In an accompanying editorial, Tobias Kurth, M.D., Sc.D., of the University of Bordeaux, France, and Mitchell S. V. Elkind, M.D., M.S., of Columbia University, New York, write that the results of this study "clearly highlight the importance of incorporating information on stroke severity when conducting health outcomes research in stroke."
"Excluding this information will lead to incorrect ranking of hospital performance by failing to consider that hospitals care for different patient populations. The influence of stroke severity on these outcome measures, moreover, seems different from that of measures of severity in other conditions. For other cardiovascular diseases, risk adjustment using demographic characteristics and claims-derived comorbid conditions may sufficiently account for the underlying case mix. Ischemic stroke is a much more heterogeneous condition than ischemic heart disease and is characterized by multiple subtypes, etiologies, and diverse outcomes. The assumption that what is true of myocardial infarction is also true of stroke, therefore, is flawed, as the present data underscore. The particular characteristics of stroke have to be taken into consideration by clinicians, insurance companies, and policy makers when comparing disease-specific health outcomes."
(JAMA. 2012;308[3]:292-293. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
###
To contact Gregg C. Fonarow, M.D., call Rachel Champeau at 310-794-2270 or email RChampeau@mednet.ucla.edu. To contact editorial co-author Tobias Kurth, M.D., Sc.D., email tobias.kurth@univ-bordeaux.fr.
END
CHICAGO – Use of the botanical product silymarin, an extract of milk thistle that is commonly used by some patients with chronic liver disease, did not provide greater benefit than placebo for patients with treatment-resistant chronic hepatitis C virus (HCV) infection, according to a study in the July 18 issue of JAMA.
Chronic hepatitis C virus infection affects almost 3 percent of the global population and may lead to cirrhosis, liver failure, and liver cancer. A large proportion of patients do not respond to certain treatments for this infection, and many others cannot ...
Stress can promote breast cancer cell colonization of bone, Vanderbilt Center for Bone Biology investigators have discovered.
The studies, reported July 17 in PLoS Biology, demonstrate in mice that activation of the sympathetic nervous system – the "fight-or-flight" response to stress – primes the bone environment for breast cancer cell metastasis. The researchers were able to prevent breast cancer cell lesions in bone using propranolol, a cardiovascular medicine that inhibits sympathetic nervous system signals.
Metastasis – the spread of cancer cells to distant organs, ...
CHICAGO – Physicians tend to share patients with colleagues who have similar personal traits and practice styles, and there is substantial variation in physician network characteristics across geographic areas, according to a study in the July 18 issue of JAMA.
Physicians are embedded in informal networks that result from their sharing of patients, information, and behaviors. "These informal information-sharing networks of physicians differ from formal organizational structures (such as a physician group associated with a health plan, hospital, or independent practice ...
CHICAGO – Among patients with relapsing-remitting multiple sclerosis (MS), treatment with the widely-prescribed drug to treat MS, interferon beta, was not associated with less progression of disability, according to a study in the July 18 issue of JAMA.
"A key feature of MS is clinical progression of the disease over time manifested by the accumulation of disability. Interferon beta drugs are the most widely prescribed disease-modifying drugs approved by the U.S. Food and Drug Administration for the treatment of relapsing-onset MS, the most common MS disease course," ...
Fewer people died or needed expensive long-term care when their physicians focused on the top risk factors for stroke and dementia, according to research reported in the Journal of the American Heart Association (JAHA). dementia
The primary care doctors in the German study focused on high blood pressure, smoking, high cholesterol, diabetes, irregular heartbeat (atrial fibrillation) and depression. The researchers found that during a five-year period, the need for long-term care was cut 10 percent in women and 9.6 percent in men.
Based on data collected in a comparison ...
Breast cancer mortality statistics in Sweden are consistent with studies that have reported that screening has limited or no impact on breast cancer mortality among women aged 40-69, according to a study published July 17 in the Journal of The National Cancer Institute.
Since 1974, Swedish women aged 40-69 have increasingly been offered mammography screening, with nationwide coverage peaking in 1997. Researchers set out to determine if mortality trends would be reflected accordingly.
In order to determine this, Philippe Autier, M.D., of the International Prevention ...
VANCOUVER – Diagnostic tests are increasingly capable of identifying plaques and tangles present in Alzheimer's disease, yet the disease remains untreatable. Questions remain about how these tests can be used in research studies examining potential interventions to treat and prevent Alzheimer's disease. Experts from the Perelman School of Medicine at the University of Pennsylvania will today participate in a panel at the Alzheimer's Association International Conference 2012 (AAIC 2012) discussing ways to ethically disclose and provide information about test results to asymptomatic ...
Even when its clot-dissolving powers are removed, the stroke drug tPA can still protect brain cells from the loss of oxygen and glucose induced by a stroke, researchers have discovered.
The finding suggests that a modified version of tPA could provide benefits to patients who have experienced a stroke, without increasing the risk of bleeding.
The results will be published in the Journal of Neuroscience.
"We may have been giving the right medication, for the wrong reason," says senior author Manuel Yepes, MD, associate professor of neurology at Emory University School ...
Radiation from Japan's Fukushima Daiichi nuclear disaster may eventually cause anywhere from 15 to 1,300 deaths and from 24 to 2,500 cases of cancer, mostly in Japan, Stanford researchers have calculated.
The estimates have large uncertainty ranges, but contrast with previous claims that the radioactive release would likely cause no severe health effects.
The numbers are in addition to the roughly 600 deaths caused by the evacuation of the area surrounding the nuclear plant directly after the March 2011 earthquake, tsunami and meltdown.
Recent PhD graduate John Ten ...
BOSTON – A new way of mapping how physicians share patients provides opportunities for improving the quality of medical care and organizing the nature of care delivery, according to researchers from Beth Israel Deaconess Medical Center and Harvard Medical School.
In a study published in the July 18 edition of the Journal of the American Medical Association, researchers suggest this new way of systematically looking at how physicians are organized into patient-sharing networks can shed light on practice variation, aid in the spread of innovation and help form natural groups ...
