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Socioeconomic Factors, Urological Epidemiology and Practice Patterns
540
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Editorial Comment: In this study the resistive index in the renal artery was measured using Doppler ultrasound in patients with medical nephropathies (glomerulonephritis, hypertension with albuminuria, interstitial nephritis). The authors divided patients into those with eGFRs less than 60 and greater than 60, and then by resistive indices greater or less than 0.7. The only independent predictor of progression to renal failure was a resistive index of greater than 0.7. Although the predictive value of the resistive index is modest, it is another parameter that might be used particularly in patients with eGFRs less than 60 to alert the clinician of a significant risk of progression to renal failure. It might also be considered in patients who are to undergo partial or total nephrectomy with a preoperative eGFR of less than 60 ml per minute as helpful in predicting those at significant risk for renal failure requiring dialysis. W. Scott, McDougal, M.D.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Hospital-Acquired Catheter-Associated Urinary Tract Infection: Documentation and Coding Issues may Reduce Financial Impact of Medicare’s New Payment Policy J. Meddings, S. Saint and L. F. McMahon, Jr. Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan Infect Control Hosp Epidemiol 2010; 31: 627– 633.
Objective: To evaluate whether hospital-acquired catheter-associated urinary tract infections (CAUTIs) are accurately documented in discharge records with the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes so that nonpayment is triggered, as mandated by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions Initiative. Methods: We conducted a retrospective medical record review of 80 randomly selected adult discharges from May 2006 through September 2007 from the University of Michigan Health System (UMHS) with secondary-diagnosis urinary tract infections (UTIs). One physician-abstractor reviewed each record to categorize UTIs as catheter associated and/or hospital acquired; these results (considered “gold standard”) were compared with diagnosis codes assigned by hospital coders. Annual use of the catheter association code (996.64) by UMHS coders was compared with state and US rates by using Healthcare Cost and Utilization Project data. Results: Patient mean age was 58 years; 56 (70%) were women; median length of hospital stay was 6 days; 50 patients (62%) used urinary catheters during hospitalization. Hospital coders had listed 20 secondary-diagnosis UTIs (25%) as hospital acquired, whereas physician-abstractors indicated that 37 (46%) were hospital acquired. Hospital coders had identified no CA-UTIs (code 996.64 was never used), whereas physician-abstractors identified 36 CA-UTIs (45%; 28 hospital acquired and 8 present on admission). Catheter use often was evident only from nursing notes, which, unlike physician notes, cannot be used by coders to assign discharge codes. State and US annual rates of 996.64 coding (approximately 1% of secondarydiagnosis UTIs) were similar to those at UMHS. Conclusions: Hospital coders rarely use the catheter association code needed to identify CA-UTI among secondary-diagnosis UTIs. Coders often listed a UTI as present on admission, although the medical record indicated that it was hospital acquired. Because coding of hospital-acquired CA-UTI seems to be fraught with error, nonpayment according to CMS policy may not reliably occur. Editorial Comment: In 2008 Medicare introduced the Hospital-Acquired Conditions Initiative, which was designed to improve outcomes and quality by eliminating additional
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
payments to hospitals for conditions that Medicare deems hospital acquired and avoidable. Included in these “never events” was catheter associated urinary tract infection. This study compared medical record review to administrative coding in 80 cases and found that catheter associated UTI was vastly underreported due to the difficulty in properly coding these cases. Of course, many of us may view this as good news but it is likely that Medicare will devise a way of more accurately capturing these cases in the future. When they do it will be of great importance to urology, as roughly 20% of the cases in the study cohort had a catheter placed for urinary outlet obstruction. David F. Penson, M.D., M.P.H.
Diagnostic Urology, Urinary Diversion and Perioperative Care Improving Surgical Site Infections: Using National Surgical Quality Improvement Program Data to Institute Surgical Care Improvement Project Protocols in Improving Surgical Outcomes C. M. Berenguer, M. G. Ochsner, Jr., S. A. Lord and C. K. Senkowski Department of Surgery, Memorial University Medical Center, Savannah, Georgia J Am Coll Surg 2010; 210: 737–743.
Background: The National Surgical Quality Improvement Program (NSQIP) began with the Veterans Affairs system to reduce morbidity and mortality by evaluating preoperative risk factors, postoperative occurrences, mortality reports, surgical site infections, and patient variable statistics. Our institution enrolled in NSQIP July 2006. The Surgical Care Improvement Project (SCIP) was developed to reduce surgical complications, including surgical infections. We began instituting SCIP protocols in July 2007. Study Design: This is a retrospective review of the NSQIP data collected by our NSQIP nurse. The colorectal surgical site infection (SSI) data pre- and post-institution of SCIP guidelines are analyzed. Data from the July 2006 to June 2007 and July 2007 to June 2008 reports are compared. Rates of SCIP compliance are analyzed. Results: There were 113 colorectal cases in the July 2006 to June 2007 NSQIP report. The rate of superficial SSI was 13.3%, with an expected rate of 9.7% (p ⫽ 0.041). The observed-to-expected ratio was 1.39. Compliance with SCIP was 38%. There were 84 colorectal cases in the July 2007 to June 2008 NSQIP report. The rate of superficial SSI was 8.3%, with an expected rate of 10.25% (p ⫽ 0.351). The observed-to-expected ratio was 0.81. Compliance with SCIP measures was 92%. Conclusions: Participation in NSQIP can identify areas of increased morbidity and mortality. Our institution was a high outlier in superficial SSI in colorectal patients during the first NSQIP evaluations. SCIP guidelines were instituted and a statistically significant reduction in our rates of SSI was realized. As our compliance with SCIP improved, our rates of superficial SSI decreased. Reduction in superficial SSI decreases cost to the patient and decreases length of stay. Editorial Comment: The authors demonstrate how their participation in and use of NSQIP can significantly decrease surgical site infections, and thereby reduce costs and length of stay for patients undergoing colorectal surgery. This finding adds further evidence that systematic use of quality parameters and processes can improve outcomes and impact not only the quality, but also the cost of patient care. Richard K. Babayan, M.D.
541
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Editorial Comment: In this study the resistive index in the renal artery was measured using Doppler ultrasound in patients with medical nephropathies (glomerulonephritis, hypertension with albuminuria, interstitial nephritis). The authors divided patients into those with eGFRs less than 60 and greater than 60, and then by resistive indices greater or less than 0.7. The only independent predictor of progression to renal failure was a resistive index of greater than 0.7. Although the predictive value of the resistive index is modest, it is another parameter that might be used particularly in patients with eGFRs less than 60 to alert the clinician of a significant risk of progression to renal failure. It might also be considered in patients who are to undergo partial or total nephrectomy with a preoperative eGFR of less than 60 ml per minute as helpful in predicting those at significant risk for renal failure requiring dialysis. W. Scott, McDougal, M.D.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Hospital-Acquired Catheter-Associated Urinary Tract Infection: Documentation and Coding Issues may Reduce Financial Impact of Medicare’s New Payment Policy J. Meddings, S. Saint and L. F. McMahon, Jr. Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan Infect Control Hosp Epidemiol 2010; 31: 627– 633.
Objective: To evaluate whether hospital-acquired catheter-associated urinary tract infections (CAUTIs) are accurately documented in discharge records with the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes so that nonpayment is triggered, as mandated by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions Initiative. Methods: We conducted a retrospective medical record review of 80 randomly selected adult discharges from May 2006 through September 2007 from the University of Michigan Health System (UMHS) with secondary-diagnosis urinary tract infections (UTIs). One physician-abstractor reviewed each record to categorize UTIs as catheter associated and/or hospital acquired; these results (considered “gold standard”) were compared with diagnosis codes assigned by hospital coders. Annual use of the catheter association code (996.64) by UMHS coders was compared with state and US rates by using Healthcare Cost and Utilization Project data. Results: Patient mean age was 58 years; 56 (70%) were women; median length of hospital stay was 6 days; 50 patients (62%) used urinary catheters during hospitalization. Hospital coders had listed 20 secondary-diagnosis UTIs (25%) as hospital acquired, whereas physician-abstractors indicated that 37 (46%) were hospital acquired. Hospital coders had identified no CA-UTIs (code 996.64 was never used), whereas physician-abstractors identified 36 CA-UTIs (45%; 28 hospital acquired and 8 present on admission). Catheter use often was evident only from nursing notes, which, unlike physician notes, cannot be used by coders to assign discharge codes. State and US annual rates of 996.64 coding (approximately 1% of secondarydiagnosis UTIs) were similar to those at UMHS. Conclusions: Hospital coders rarely use the catheter association code needed to identify CA-UTI among secondary-diagnosis UTIs. Coders often listed a UTI as present on admission, although the medical record indicated that it was hospital acquired. Because coding of hospital-acquired CA-UTI seems to be fraught with error, nonpayment according to CMS policy may not reliably occur. Editorial Comment: In 2008 Medicare introduced the Hospital-Acquired Conditions Initiative, which was designed to improve outcomes and quality by eliminating additional
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
payments to hospitals for conditions that Medicare deems hospital acquired and avoidable. Included in these “never events” was catheter associated urinary tract infection. This study compared medical record review to administrative coding in 80 cases and found that catheter associated UTI was vastly underreported due to the difficulty in properly coding these cases. Of course, many of us may view this as good news but it is likely that Medicare will devise a way of more accurately capturing these cases in the future. When they do it will be of great importance to urology, as roughly 20% of the cases in the study cohort had a catheter placed for urinary outlet obstruction. David F. Penson, M.D., M.P.H.
Diagnostic Urology, Urinary Diversion and Perioperative Care Improving Surgical Site Infections: Using National Surgical Quality Improvement Program Data to Institute Surgical Care Improvement Project Protocols in Improving Surgical Outcomes C. M. Berenguer, M. G. Ochsner, Jr., S. A. Lord and C. K. Senkowski Department of Surgery, Memorial University Medical Center, Savannah, Georgia J Am Coll Surg 2010; 210: 737–743.
Background: The National Surgical Quality Improvement Program (NSQIP) began with the Veterans Affairs system to reduce morbidity and mortality by evaluating preoperative risk factors, postoperative occurrences, mortality reports, surgical site infections, and patient variable statistics. Our institution enrolled in NSQIP July 2006. The Surgical Care Improvement Project (SCIP) was developed to reduce surgical complications, including surgical infections. We began instituting SCIP protocols in July 2007. Study Design: This is a retrospective review of the NSQIP data collected by our NSQIP nurse. The colorectal surgical site infection (SSI) data pre- and post-institution of SCIP guidelines are analyzed. Data from the July 2006 to June 2007 and July 2007 to June 2008 reports are compared. Rates of SCIP compliance are analyzed. Results: There were 113 colorectal cases in the July 2006 to June 2007 NSQIP report. The rate of superficial SSI was 13.3%, with an expected rate of 9.7% (p ⫽ 0.041). The observed-to-expected ratio was 1.39. Compliance with SCIP was 38%. There were 84 colorectal cases in the July 2007 to June 2008 NSQIP report. The rate of superficial SSI was 8.3%, with an expected rate of 10.25% (p ⫽ 0.351). The observed-to-expected ratio was 0.81. Compliance with SCIP measures was 92%. Conclusions: Participation in NSQIP can identify areas of increased morbidity and mortality. Our institution was a high outlier in superficial SSI in colorectal patients during the first NSQIP evaluations. SCIP guidelines were instituted and a statistically significant reduction in our rates of SSI was realized. As our compliance with SCIP improved, our rates of superficial SSI decreased. Reduction in superficial SSI decreases cost to the patient and decreases length of stay. Editorial Comment: The authors demonstrate how their participation in and use of NSQIP can significantly decrease surgical site infections, and thereby reduce costs and length of stay for patients undergoing colorectal surgery. This finding adds further evidence that systematic use of quality parameters and processes can improve outcomes and impact not only the quality, but also the cost of patient care. Richard K. Babayan, M.D.
541