Accepting critically ill transfer patients: adverse effects on a referral center?s outcome and benchmark measures

Article Abstract:

Background: Common methods of benchmarking clinical performance rarely, if ever, account for admission source and, in particular, the effect of a patient being transferred from one medical center to another. Small biases in comparisons of observed versus expected deaths can substantially affect how high-quality institutions compare with peer hospitals. With the most sophisticated and validated set of case-mix measures available for patients, the intensive care unit is an ideal setting in which to study the effect of a patient?s being transferred from another hospital. Objective: To determine the extent of bias in benchmarking outcomes when performance measures do not account for transfer patients? greater severity of illness. Design: Prospectively developed cohort study. Setting: Medical intensive care unit (MICU) at a tertiary care university hospital. Patients: 4579 consecutive admissions for 4208 patients from 1 January 1994 to 1 April 1998. Measurements: MICU and hospital lengths of stay, MICU readmission, and hospital mortality rates. Results: Compared with directly admitted patients, MICU patients transferred from another hospital had significantly higher Acute Physiology Scores at the time of admission and discharge (P=0.001). Even after full adjustment for case mix and severity of illness, transfer patients had a 38% longer MICU stay (95% CI, 32% to 45%), a 41% longer hospital stay (CI, 34% to 50%), and a 2.2 times greater odds of hospital mortality (CI, 1.7 to 2.8) than directly admitted patients. With identical efficiency and quality, a referral hospital with a 25% MICU transfer rate compared with another with a 0% transfer rate would be penalized by 14 excess deaths per 1000 admissions when a benchmarking program adjusts only for case mix and severity of illness and not for the source of admission. Conclusions: In a setting with the most thorough diagnostic-based, case-mix adjustment and the most physiologically precise severity-of-illness information, accepting transfer patients can adversely affect efficiency and quality benchmarks. Benchmarking and profiling efforts beyond intensive care units must also recognize and account for this phenomenon: otherwise, referral centers may have an incentive to refuse care for patients who could benefit from being transferred to their facility.

Hospital patients, Author Abstract

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Estimated benefits of glycemic control in microvascular complications in type 2 diabetes

Article Abstract:

By keeping rigid control over their blood glucose levels, patients with type 2 diabetes may significantly reduce their risk of blindness and kidney failure due to microvascular complications. The risks and benefits of intensive intervention to lower blood glucose levels in diabetics were explored using a mathematical model. Patients who developed type 2 diabetes at an earlier age had the greatest reduction of risk resulting from the strict regulation of blood sugar. Achieving moderate control conferred relatively greater benefits than tight control in older-onset patients.

Management, Prevention, Complications and side effects, Type 2 diabetes, Blood sugar, Blood glucose, Diabetic retinopathy, Diabetic nephropathies

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Accepting critically ill transfer patients

Article Abstract:

Hospitals that accept patients transferred from another hospital may appear to have higher death rates than other hospitals. This occurs because transferred patients are usually very sick, which is exactly why they are transferred to another hospital. So-called 'report cards' on a hospital's performance must take this into account when analyzing hospital death rates. Otherwise these hospitals will appear to be worse than hospitals that do not accept transfer patients.

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