The study was open to selection bias as patient collection was only done during the day, so eligible subjects may have been missed. Moreover, though the study suggests that capnography has a role in ruling out DKA, the exact cutoff value is unclear. Other studies found that higher values were needed to exclude diagnosis.
Bottom line: Using ETCO2 values >24.5 mmHg, capnography can help exclude the diagnosis of DKA in adult patients with elevated BG.
Citation: Soleimanour H, Taghizadieh A, Niafar M, Rahmani F, Golzari S, Esfanjani RM. Predictive value of capnography for diagnosis in patients with suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013. doi: 10.5811/westjem.2013.4.14296.
Publicly Reported Mortality Correlates with Overall Mortality
Clinical question: Are publicly reported mortality rates associated with a hospital’s overall medical and surgical mortality rate?
Background: Public reporting of mortality has become an important strategy in Medicare’s quality-improvement initiative. However, the mortality rate for only three conditions, acute myocardial infarction, congestive heart failure, and pneumonia are reported. It is unclear if these rates correlate to a hospital’s overall mortality rate.
Study design: Retrospective cohort.
Setting: National Medicare fee-for-service population.
Synopsis: Using 2008-2009 data from 2,322 acute-care hospitals with 6.7 million admissions, an aggregate mortality rate for the three publicly reported conditions, a standardized 30-day mortality rate for selected medical and surgical conditions, and an overall average composite mortality score was calculated for each hospital. Based on their mortality for the three publicly reported conditions, hospitals were grouped into quartiles from highest (top-performing hospitals) to lowest mortality (poor-performing hospitals).
Top-performing hospitals had a 3.6% (9.4%vs 13.0%; P<.001) lower mortality rate than poor-performing hospitals and an odds ratio >5 of being a top performer in overall mortality (OR 5.3; 95% CI, 4.3-6.5). They also had an 81% lower chance of being in the worst-performing quartile in overall mortality (OR 0.19; 95% CI, 0.14-0.27). Conversely, poor-performing hospitals had a 4.5 times higher risk of being in the lowest quartile in overall mortality. The study is limited by the use of administrative data, which limits the ability to adjust for severity of illness, overall health, and socioeconomic status of each hospital’s population.
Bottom line: A hospital’s mortality performance on the three publicly reported conditions may predict mortality rates across a wide range of medical and surgical conditions.
Citation: McCrum ML, Joynt KE, Orav EJ, Gawande AA, Jha AK. Mortality for publicly reported conditions and overall hospital mortality rates. JAMA Intern Med. 2013;173:1351-1357.
Cost Savings in Decreasing Preventable Acute-Care Visits Are Limited among High-Cost Medicare Utilizers
Clinical question: What role do preventable acute-care visits play in the overall costs of care for the highest Medicare utilizers?
Background: Some 10% of Medicare patients account for more than half the costs. Interventions targeted at decreasing acute-care costs (ED visits and inpatient hospitalizations) for this high-cost population are widespread, but it is unknown what impact they can have.
Study design: Retrospective cohort.
Setting: National Medicare fee-for-service population.
Synopsis: Standardized total costs were created for fee-for-service Medicare patients for 2009 and 2010 in order to identify high-cost and persistently high-cost patients. Algorithms were used to identify preventable ED visits and hospitalizations in both the high-cost and non-high-cost cohorts.
Of the more than 1 million patients in the sample Medicare population, as many as 113,341 were high-cost. As much as 73% of acute-care spending was attributable to this cohort. Overall, 10% of acute-care costs were felt to be preventable in the high-cost group, 13.5% in the persistently high-cost group, and 19% in the non-high-cost group for 2010. The most common reasons for preventable acute care in the high-cost cohort were heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease. Catastrophic events (myocardial infarction, stroke, sepsis), cancer, and orthopedic procedures drove overall inpatient costs in the high-cost group.