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Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years

Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years Following ACGME Resident Hour Reform. Amy Rosen, Ph.D.

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Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years

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  1. Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years Following ACGME Resident Hour Reform Amy Rosen, Ph.D. Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC Boston University School of Public Health, Health Policy and Management Department, Boston, MA AcademyHealth ● June 2008 Supported by VA HSR&D IIR# 04.202.1 and NHLBI ROI HL 082637

  2. Co-Investigators Susan Loveland, M.A.T.1,2 Patrick Romano, M.D., M.P.H.3 Kamal Itani, M.D.4 Paul Rosenbaum, Ph.D.5 Jeffrey Silber, M.D., Ph.D.5,6,7,8 Orit Even-Shoshan, M.S.6,7 Michael Halenar, B.A.6,9 Yun Teng, M.S.7 Jingsan Zhu, M.B.A.6 Kevin Volpp, M.D., Ph.D.5,6,7,8,9 1 Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC 2 Boston University School of Public Health, Health Policy and Management Department 3University of California at Davis, School of Medicine, Division of General Medicine and Center for Healthcare Policy and Research 4Boston VA Healthcare System and Boston University, Departments of Surgery 5University of Pennsylvania, The Wharton School 6University of Pennsylvania, School of Medicine 7Center for Outcomes Research, The Children’s Hospital of Philadelphia 8The Leonard Davis Institute of Health Economics, The University of Pennsylvania 9Center of Health Equity Research and Promotion, VA Center of Excellence, Philadelphia VAMC

  3. Background • ACGME duty hours regulations implemented on July 1, 2003 to improve safety • Do duty hour regulations improve or worsen patients outcomes in more vs. less teaching-intensive hospitals? • Previous work shows slight improvement in mortality for VA patients with common medical conditions • Little evidence on the effect of ACGME on other outcomes

  4. Objectives and Hypotheses • To investigate whether rates of the AHRQ Patient Safety Indicators (PSIs) changed following ACGME duty hour reforms in more vs. less teaching-intensive hospitals in VA. • Hypotheses: (1) Rates of technical skill-based PSIs (e.g. iatrogenic pneumothorax) would improve (2) Rates of PSIs related to continuity of care (e.g. postoperative sepsis) would worsen (3) Rates of PSIs reflecting collaborative care (e.g. postoperative hip fracture) would not change

  5. Study Population • All unique patients (n=828,534) admitted to acute-care VA hospitals (n=131) between July 1, 2000 and June 30, 2005 • Index admission: first admission for which there was no prior admission eligible for a given PSI composite within 5 years • Exclusions from VA inpatient data: • Admissions to hospitals outside the US (n=41,928) • Transfers from non-VA hospitals (n=31,049) • Admissions spanning July 1, 2003 (n=6,809) • Admissions for patients older than 90 years (n=11,398)

  6. Data Sources/Years • VA inpatient data files (VA Patient Treatment File) for diagnoses, age, gender, and discharge status • Veterans Health Administration Support Service Center Occupancy Rate Reports for number of beds per hospital • VA Office of Academic Affiliations for number of residents • Pre-reform period: pre-year 3 (7/01/00-6/30/01), pre-year 2 (7/01/01-6/30/02), and pre-year 1 (7/01/01-6/30/03) • Post-reform period: post-year 1 (7/01/03-6/30/04) and post-year 2 (7/01/04-6/30/05)

  7. Teaching Intensity • Measured by the resident-to-bed ratio (RTB ratio) • Calculated as the number of interns plus residents divided by the mean number of operational beds • Minor teaching: RTB ratio >0 - <0.25 • Major teaching: RTB ratio >0.25 - <0.60 • Very major teaching: RTB ratio >0.60

  8. PSI Composites • Technical Care (795,306 admissions) • Iatrogenic pneumothorax • Foreign body left in during procedure • Accidental puncture or laceration • Postoperative hemorrhage or hematoma • Continuity of Care (339,504 admissions) • Postoperative physiologic or metabolic derangement • Postoperative pulmonary embolism/deep vein thrombosis (PE/DVT) • Postoperative sepsis • Collaborative Care (653,270 admissions) • Postoperative hip fracture • Postoperative respiratory failure • Selected infections due to medical care

  9. Analysis • Multiple time series research design • Conditional logistic regression models adjusted for age, gender, comorbidities, secular trends, baseline severity, and stratifying on hospital site • Odds ratios measure the degree to which PSI composite rates change differently in more vs. less teaching-intensive hospitals • Tested stability by eliminating patients admitted to hospitals in NY State and those patients admitted from nursing homes

  10. Description of VA Sample

  11. Hospital Characteristics by Teaching Status in VA

  12. Group 1 ( 0 ) Group 2: (>0.0 - <=0.25) Group 3 (>0.25 - <=0.6) Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

  13. Group 1 ( 0 ) Group 2: (>0.0 - <=0.25) Group 3 (>0.25 - <=0.6) Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

  14. Group 1 ( 0 ) Group 2: (>0.0 - <=0.25) Group 3 (>0.25 - <=0.6) Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

  15. Adjusted Odds of PSI Composite Events After Duty Hour Reform in More vs. Less Teaching-Intensive VA Hospitals

  16. Possible Explanations for No Major Changes in PSI Rates • Residents get more sleep, but there are also increased handoffs • Residents can still work 30 hours straight • Compliance may not be high

  17. Strengths/Limitations • Strengths • National sample of patients from the VA • Difference-in-difference approach to reduce likelihood of confounding • Utilization of standardized measures of patient safety • Limitations • No clinical data for risk adjustment • Limitations in using PSIs to measure patient safety • Unmeasured confounding

  18. Conclusions • Rates of Technical Care PSI composite did not improve between more vs. less teaching-intensive hospitals over time • Rates of Continuity of Care PSI composite did not worsen - we saw a slight trend in worsening rates in post-reform year 2 in more teaching-intensive hospitals • Rates of Collaborative Care PSI increased slightly over time (only in post-reform year 2) in more teaching-intensive hospitals, marginally significant increase (p=0.04)

  19. Implications • Implementation of ACGME had no overall systematic impact on patient safety in more vs. less teaching-intensive hospitals • Lack of improvement in any of the PSI composites suggests that more work is needed to improve safety • Need to examine the effects of ACGME beyond first 2 years • Need more data on facilitators and barriers to improvements in clinical outcomes

  20. Thank you!

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