Objective: To assess variation in safety climate across VA hospitals nationally.

Study Setting: Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.

Study Design: We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).

Data Collection: Data were collected using an anonymous survey design.

Principal Findings: We received 4,547 responses (49 percent response rate). The percent problematic response-lower percent reflecting higher levels of patient safety climate-ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.

Conclusions: This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

Abstract

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.

Black patients receiving dialysis for end-stage renal disease in the United States have lower mortality rates than white patients. Whether racial differences exist in mortality after acute renal failure is not known. We studied acute renal failure in patients hospitalized between 2000 and 2003 using the Nationwide Inpatient Sample and found that black patients had an 18% (95% confidence interval [CI] 16 to 21%) lower odds of death than white patients after adjusting for age, sex, comorbidity, and the need for mechanical ventilation. Similarly, among those with acute renal failure requiring dialysis, black patients had a 16% (95% CI 10 to 22%) lower odds of death than white patients. In stratified analyses of patients with acute renal failure, black patients had significantly lower adjusted odds of death than white patients in settings of coronary artery bypass grafting, cardiac catheterization, acute myocardial infarction, congestive heart failure, pneumonia, sepsis, and gastrointestinal hemorrhage. Black patients were more likely than white patients to be treated in hospitals that care for a larger number of patients with acute renal failure, and black patients had lower in-hospital mortality than white patients in all four quartiles of hospital volume. In conclusion, in-hospital mortality is lower for black patients with acute renal failure than white patients. Future studies should assess the reasons for this difference.

Background: Women with acute myocardial infarction have a higher hospital mortality rate than men. This difference has been ascribed to their older age, more frequent comorbidities, and less frequent use of revascularization. The aim of this study is to assess these factors in relation to excess mortality in women.

Methods and Results All hospital admissions in France with a discharge diagnosis of acute myocardial infarction were extracted from the national payment database. Logistic regression on mortality was performed for age, comorbidities, and coronary interventions. Nonparametric microsimulation models estimated the percutaneous coronary intervention and mortality rates that women would experience if they were "treated like men." Data were analyzed from 74 389 patients hospitalized with acute myocardial infarction, 30.0% of whom were women. Women were older (75 versus 63 years of age; P0.001) and had a higher rate of hospital mortality (14.8% versus 6.1%; P0.0001) than men. Percutaneous coronary interventions were more frequent in men (7.4% versus 4.8%; 24.4% versus 14.2% with stent; P0.001). Mortality adjusted for age and comorbidities was higher in women (P0.001), with an excess adjusted absolute mortality of 1.95%. Simulation models related 0.46% of this excess to reduced use of procedures. Survival benefit related to percutaneous coronary intervention was lower among women.

Conclusions The difference in mortality rate between men and women with acute myocardial infarction is due largely to the different age structure of these populations. However, age-adjusted hospital mortality was higher for women and was associated with a lower rate of percutaneous coronary intervention. Simulations suggest that women would derive benefit from more frequent use of percutaneous coronary intervention, although these procedures appear less protective in women than in men.

Background: In 2002, the Accreditation Council on Graduate Medical Education enacted regulations, effective 1 July 2003, that limited work hours for all residency programs in the United States.

Objective: To determine whether work-hour regulations were associated with changes in mortality in hospitalized patients.

Design: Comparison of mortality rates in high-risk teaching service patients hospitalized before and after July 2003, with nonteaching service patients used as a control group.

Setting: 551 U.S. community hospitals included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Survey between January 2001 and December 2004.

Patients: 1,511,945 adult patients admitted for 20 medical and 15 surgical diagnoses.

Measurement: Inpatient mortality.

Results: In 1,268,738 medical patients examined, the regulations were associated with a 0.25% reduction in the absolute mortality rate (P = 0.043) and a 3.75% reduction in the relative risk for death. In subgroup analyses, particularly large improvements in mortality were observed among patients admitted for infectious diseases (change, -0.66%; P = 0.007) and in medical patients older than 80 years of age (change, -0.71%; P = 0.005). By contrast, in 243 207 surgical patients, regulations were not associated with statistically significant changes (change, 0.13%; P = 0.54).

Limitations: Teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available. Results reflect changes associated with the sum of regulations, not specifically with caps on work hours.

Conclusions: The work-hour regulations were associated with decreased short-term mortality among high-risk medical patients in teaching hospitals but were not associated with statistically significant changes among surgical patients in teaching hospitals.

Background: Carotid endarterectomy (CEA) has been shown to decrease future ischemic stroke risk in selected patients. However, clinical trials did not examine the risk-benefit ratio for nonwhites, who have a greater ischemic stroke risk than whites. In general, few studies have examined the effects of race on CEA use and complications, and data on race and CEA readmission are lacking.

Methods: This study used administrative data for patients discharged from California hospitals between January 1 and December 31, 2000. Selection criteria of cases included: ICD-9 principal procedure code 38.12, principal diagnostic code 433 and diagnosis-related group 5. There were 8,080 white and 1196 nonwhite patients (228 blacks, 643 Hispanics, 325 Asians/Pacific Islanders) identified that underwent an elective and isolated CEA. For both groups, CEA rates were compared. Logistic regression was used to examine the independent effects of race on in-hospital death and stroke, as well as CEA readmission.

Results: Rates of CEA use were more than three times greater for whites than nonwhites, although nonwhites were more likely to have symptomatic disease. For all patients, the complication rate was 1.9%. However, the odds of in-hospital death and stroke were greater for nonwhites than whites, but after adjustment for patient and hospital factors, these differences were only significant for stroke (OR = 1.7, P = 0.013). For both outcomes, the final models had good predictive accuracy. Overall, CEA readmission risk was 7%, and no significant racial differences were observed (P = 0.110).

Conclusions: The data suggest that CEA is performed safely in California. However, nonwhites had lower rates of initial CEA use but higher rates of in-hospital death and stroke than whites. Racial differences in stroke risk persisted after adjustment for patient and hospital factors. Finally, this study found that despite significant racial disparities in initial CEA use, whites and nonwhites were similar in their CEA readmission rates. These findings may suggest that screening initiatives are lacking for nonwhites, which may increase their risk for poorer outcomes.

Background: There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants.

Methods: We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000.

Results: Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries.

Conclusions: Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.