Rationale: Prehospital opportunities to predict infection and sepsis hospitalization may exist, but little is known about their incidence following common healthcare encounters. Objectives: To evaluate the incidence and timing of infection and sepsis hospitalization within 7 days of living hospital…
The development of a shared data infrastructure across health systems could improve research, clinical care, and health policy across a spectrum of diseases, including sepsis. Awareness of the potential value of such infrastructure has been heightened by COVID-19, as the…
Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or…
Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings. The objective of this study was to test the feasibility of hospital-specific…
This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population. Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from…
To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. Observational study. 21 hospitals operated by Kaiser Permanente Northern California.…
This study will characterize and compare antecedents to hospitalization and in-hospital deterioration among patients with COVID-19 and comparator patients with influenza. We will quantify pre-existing comorbidities, medication adherence, and temporal factors prior to hospitalization with COVID-19 or influenza. We will…
To examine the value of health systems data as indicators of emerging COVID-19 activity. Observational study of health system indicators for the COVID Hotspotting Score (CHOTS) with prospective validation. An integrated healthcare delivery system in Northern California including 21 hospitals…
Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or…
Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes. Retrospective cohort study (1 February 2020 to 31 May 2020). Integrated health care delivery…
To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes. A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from…
This project aims to improve The Permanente Medical Group's capability for outpatient and population management of adults with COVID-19. It will identify the spatial, temporal, and racial distribution of coronavirus infections; characterize the clinical progression of coronavirus infection; and synthesize…
An increasing number of delivering women experience major morbidity and mortality. Limited work has been done on automated predictive models that could be used for prevention. Using only routinely collected obstetrical data, this study aimed to develop a predictive model…
Background: A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for…
To assess both the feasibility and potential impact of predicting preventable hospital readmissions using causal machine learning applied to data from the implementation of a readmissions prevention intervention (the Transitions Program). Electronic health records maintained by Kaiser Permanente Northern California…
Hospitalized adults whose condition deteriorates while they are in wards (outside the intensive care unit [ICU]) have considerable morbidity and mortality. Early identification of patients at risk for clinical deterioration has relied on manually calculated scores. Outcomes after an automated…
Chronic obstructive pulmonary disease (COPD) is a common and costly reason for hospitalization and rehospitalization. The Hospital Readmissions Reduction Program penalizes hospitals for excess, non-elective, all-cause 30-day, inpatient rehospitalizations for COPD. We sought to determine how broadening the outcome definition…
Rationale: Prior approaches to measuring healthcare capacity strain have been constrained by using individual care units, limited metrics of strain, or general, rather than disease-specific, populations.Objectives: We sought to develop a novel composite strain index and measure its association with…
Prediction models are widely used in health care as a way of risk stratifying populations for targeted intervention. Most risk stratification has been done using a small number of predictors from insurance claims. However, the utility of diverse nonclinical predictors,…
Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template…
The SRI team will (a) assess results of previous internal and external deployments of alternatives to hospitalization, (b) define strategies to quantify the potential pool of Kaiser Permanente Northern California patients who would be eligible for such alternatives, (c) develop…
To examine whether and how step-down unit admission after ICU discharge affects patient outcomes. Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU…
Risk scores used in early warning systems exist for general inpatients and patients with suspected infection outside the intensive care unit (ICU), but their relative performance is incompletely characterized. To compare the performance of tools used to determine points-based risk…
To assess trends over time in red blood cell (RBC) transfusion practice among emergency department (ED) patients with gastrointestinal (GI) bleeding within an integrated healthcare system, inclusive of 21 EDs. Retrospective cohort of ED patients diagnosed with GI bleeding between…
Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning…
The goal of this project is to assist with measure development and testing for the Hospital-Wide Mortality (HWM) hybrid and HWM claims-only measures. This includes providing consulting support to the Yale Center for Outcomes Research and Evaluation team and defining…
Professional societies have developed recommendations for patient triage protocols, but wide variations in triage patterns for many acute conditions exist among hospitals in the United States. Differences in hospitals' triage patterns can be attributed to factors such as physician behavior,…
Acute respiratory failure requiring mechanical ventilation is a leading cause of mortality in the intensive care unit. Although single peripheral blood oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratios of hypoxemia have been evaluated to risk-stratify patients with acute respiratory distress…
Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive…
To use unsupervised topic modeling to evaluate heterogeneity in sepsis treatment patterns contained within granular data of electronic health records. A multicenter, retrospective cohort study of 29 253 hospitalized adult sepsis patients between 2010 and 2013 in Northern California. We…
Significant research has focused individually on blood donors, product preparation and storage, and optimal transfusion practice. To better understand the interplay between these factors on measures of red blood cell (RBC) transfusion efficacy, we conducted a linked analysis of blood…
Pharmacists are an expensive and limited resource in the hospital and outpatient setting. A pharmacist can spend up to 25% of their day planning. Time spent planning is time not spent delivering an intervention. A readmission risk adjustment model has…
The clinical deterioration of patientsin general hospital wards is an important safety issue. Aggregate-weighted early warning systems (EWSs) may not detect risk until patients present with acute decline. We aimed to compare the prognostic test accuracy and clinical workloads generated…
Compared to adults admitted to general medical-surgical wards, women admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk…
Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described. To describe the prevalence of anemia at and after hospital…
Intensive care unit (ICU) capacity strain refers to the potential limits placed on an ICU's ability to provide high-quality care for all patients who may need it at a given time. Few studies have investigated how fluctuations in ICU capacity…
This project aims to develop a set of algorithms for generic error detection, prevention, and mitigation in the hospital setting. The goal is to develop algorithms that can operate in real time so as to support an existing infrastructure (the…
We sought to determine the proportion of bronchiolitis episodes attributable to respiratory syncytial virus (RSV) among ICD-9 coded infant bronchiolitis episodes which were tested for RSV. Bronchiolitis healthcare encounters were extracted from Kaiser Permanente Northern California databases for years 2006…
This project aims to determine whether fields included in the National Institutes of Health’s Patient Reported Outcomes Measurement System (PROMIS) questionnaires for cognition and physical function, as well as those in the Your Current Life Situation (YCLS) questionnaire can enhance…
Research investigating risk factors for hospital-acquired pressure injury (HAPI) has primarily focused on the characteristics of patients and nursing staff. Limited data are available on the association of hospital characteristics with HAPI. We aimed to quantify the association of hospital…
The new Kaiser Permanente Your Current Life Situation (YCLS) screening questionnaire will be mailed to a random sample of 7,000 adult members of Kaiser Permanente Northern California (KPNC), oversampling patients at low to medium risk for hospitalization. After receiving responses,…
To estimate the impact of each of six types of acute organ dysfunction (hepatic, renal, coagulation, neurologic, cardiac, and respiratory) on long-term mortality after surviving sepsis hospitalization. Multicenter, retrospective study. Twenty-one hospitals within an integrated healthcare delivery system in Northern…
This study aims to determine whether specific items from two questionnaires currently in use at Kaiser Permanente Northern California (the Your Current Life Situation questionnaire and selected functional status questionnaires from the National Institutes of Health’s Patient Reported Outcomes Measurement…
This study aims to employ machine learning methods to develop predictive models for adverse drug events, or ADEs, that result in patients using the emergency department and/or being hospitalized (non-nosocomial ADEs, NNADEs). Based on work with a pharmacist expert panel…
To quantify healthcare utilization in the week preceding sepsis hospitalization to identify potential opportunities to improve the recognition and treatment of sepsis prior to admission. Retrospective study. Two large integrated healthcare delivery systems in the United States. Hospitalized sepsis patients.…
Determining the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes for postpartum hemorrhage (PPH) is vital for reaching valid conclusions about the epidemiology of PPH. Our primary objectives were to assess the performance characteristics of ICD-9…
We sought to build on the template-matching methodology by incorporating longitudinal comorbidities and acute physiology to audit hospital quality. Patients admitted for sepsis and pneumonia, congestive heart failure, hip fracture, and cancer between January 2010 and November 2011 at 18…
This is a feasibility study to determine whether data from Kaiser Permanente HealthConnect® can be harnessed to predict obstetric complications in real time. The long-term goal is to develop algorithms that could be instantiated in the electronic record to provide…
This is a pilot study to determine the feasibility of conducting a prospective study that aims to characterize longitudinal trajectories among patients with pneumonia. To achieve this goal, we will attempt to enroll 150 pneumonia patients at the time of…
We sought to determine the real-world effectiveness of respiratory syncytial virus (RSV) immunoprophylaxis in a population-based cohort to inform policy. The study population included infants born 1996-2008 and enrolled in Kaiser Permanente Northern California. During the RSV season (November-March), RSV…
Although healthcare organizations have decreased hospital-acquired pressure injury (HAPI) rates, HAPIs are not eliminated, driving further examination in both nursing and health services research. The objective was to describe HAPI incidence, risk factors, and risk-adjusted hospital variation within a California…
This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in…
Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients' shared needs. However, objective methods for identifying these ICU patient subgroups…
Prior sepsis studies evaluating antibiotic timing have shown mixed results. To evaluate the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration. Retrospective study of 35,000 randomly selected inpatients with…
BACKGROUND Predicting recurrent Clostridium difficile infection (rCDI) remains difficult. We employed a retrospective cohort design. Granular electronic medical record (EMR) data had been collected from patients hospitalized at 21 Kaiser Permanente Northern California hospitals. The derivation dataset (2007-2013) included data…
Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative…
Little is known about variation in patterns of recovery among patients discharged alive from hospitalizations for pneumonia.The aim of the is observational cohort study was to characterize the variation in patterns of hospital readmission and survival in the year after…
Current algorithms for management of neonatal early-onset sepsis (EOS) result in medical intervention for large numbers of uninfected infants. We developed multivariable prediction models for estimating the risk of EOS among late preterm and term infants based on objective data…
We will study the impact of the change in the American Academy of Pediatrics's palivizumab recommendations in a large cohort of infants (300,000) of all gestations over a 7-year period (2010- 2016). We will quantify and characterize the following over…
This is a methodological study that will utilize our established PRIMA cohort to develop statistical methods for (a) quantifying and categorizing recurrent events, and (b) developing approaches for latent variable analyses. The PRIMA dataset is a joint KPNC-Tennessee Medicaid infant…
This project aims to test the impact of changing the default mode for palliative care consultation in hospitalized patients from an "opt in" to an "opt out" model. This will be tested in 10-12 Ascension Health hospitals using a stepped…
This project aims to lay the groundwork for collaborative nursing research effort involving both Kaiser Permanente California regions. Its initial focus is hospital-based and has two aims: 1) Establishing governance mechanisms that will facilitate and accelerate inter-regional collaboration with respect…
The Systems Research Initiative will provide project management and operational consultation for the spread of the Advance Alert Monitor within KPNC between 10/1/16 and 9/30/18. During this time Division of Research will complete the following tasks: continue the support of…
This project aims to test the feasibility of employing clinical data from comprehensive electronic medical record systems (such as the Epic EMR) for developing, testing and validating potential publicly-reported quality, process, outcomes and risk-adjustment measures on hospitalized adult patients.
An electronic alert system targeting adult patients in 3 hospital units (ward, telemetry, and transitional care unit) will be deployed at two KPNC hospitals (South San Francisco and Sacramento). The alert system provides early (12 hours) warning about a patient's…
The goal of this project is to conduct simulation analyses using an existing dataset (from our AHRQ-funded PRIMA study) to assess the possible risks and benefits of immunoprophylaxis among babies 35-36 weeks gestation.
This project will employ simulation methods to analyze emergency department, hospital, and ICU data, including physiologic markers of severity of illness, with a view to identifying specific patient flow, hospital and ED occupancy states, and processes of care (e.g., early…
This project will examine predictors of and outcomes after recurrent Clostridium difficile infection in adults. Predictors will include age, sex, diagnoses, severity of illness, hospital length of stay, and antibiotic exposure. Outcomes will include hospital utilization, particularly use of intensive…
This project, a collaboration with Dr. Alex Butwick at Stanford University, aims to investigate the prevalence and incidence of early postpartum anemia in patients following Cesarean delivery prior to hospital discharge over a 5-year period. As part of this project,…
Postpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage [PPH]) with severe postpartum anemia after…
Sepsis is a leading cause of in-hospital death, and evidence suggests a higher mortality in patients presenting with sepsis on the ward compared to those presenting to the emergency department. Ward patients who develop severe sepsis may have poor outcomes…
Patients who deteriorate in the hospital outside the intensive care unit (ICU) have higher mortality and morbidity than those admitted directly to the ICU. As more hospitals deploy comprehensive inpatient electronic medical records (EMRs), attempts to support rapid response teams…
Patients who deteriorate outside the intensive care unit (ICU) are known to have elevated mortality and morbidity. Rapid response teams (RRTs) were developed to address such deterioration. It has not been possible to establish that RRTs employing manual detection methods…
The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains…
Given the high mortality experienced by patients who deteriorate outside the intensive care unit, issues related to patient preferences around escalation of care are common. However, the literature on early warning systems (EWSs) provides limited information on how respecting patient…
Patients in general medical-surgical wards who experience unplanned transfer to the intensive care unit (ICU) show evidence of physiologic derangement 6 to 24 hours prior to their deterioration. With increasing availability of electronic medical records (EMRs), automated early warning scores…
The US health care system is rapidly adopting electronic health records, which will dramatically increase the quantity of clinical data that are available electronically. Simultaneously, rapid progress has been made in clinical analytics-techniques for analyzing large quantities of data and…
The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS)…
To employ automated bed data to examine whether ICU occupancy influences ICU admission decisions and patient outcomes. Retrospective study using an instrumental variable to remove biases from unobserved differences in illness severity for patients admitted to ICU. Fifteen hospitals in…
Treatments for patients with sepsis with intermediate lactate values (?2 and
To evaluate process metrics and outcomes after implementation of the "Rethinking Critical Care" ICU care bundle in a community setting. Retrospective interrupted time-series analysis. Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system. ICU patients admitted between…
The recent explosion in available electronic health record (EHR) data is motivating a rapid expansion of electronic health care predictive analytic (e-HPA) applications, defined as the use of electronic algorithms that forecast clinical events in real time with the intent…
Hospital discharge planning has been hampered by the lack of predictive models. To develop predictive models for nonelective rehospitalization and postdischarge mortality suitable for use in commercially available electronic medical records (EMRs). Retrospective cohort study using split validation. Integrated health…
Metrics typically used to report the performance of an early warning score (EWS), such as the area under the receiver operator characteristic curve or C-statistic, are not useful for pre-implementation analyses. Because physiological deterioration has an extremely low prevalence of…
To assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2). Retrospective cohort study of patients…
Blood conservation strategies have been shown to be effective in decreasing red blood cell (RBC) utilization in specific patient groups. However, few data exist describing the extent of RBC transfusion reduction or their impact on transfusion practice and mortality in…
Sepsis, the most expensive cause of hospitalization in the United States, is associated with high morbidity and mortality. However, healthcare utilization patterns following sepsis are poorly understood. To identify patient-level factors that contribute to postsepsis mortality and healthcare utilization. A…
The absolute neutrophil count and the immature/total neutrophil ratio (I/T) provide information about the risk of early onset sepsis in newborns. However, it is not clear how to combine their potentially overlapping information into a single likelihood ratio. We obtained…
Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions…
Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge healthcare use. To measure inpatient healthcare use of severe sepsis survivors compared with patients' own presepsis resource…
Lung-related research primarily focuses on the etiology and management of diseases. In recent years, interest in primary prevention has grown. However, primary prevention also includes "health promotion" (actions in a population that keep an individual healthy). We encourage more research…
Risk-adjusted mortality rates are commonly used in quality report cards to compare hospital performance. The risk adjustment depends on models that are assessed for goodness-of-fit using various discrimination and calibration measures. However, the relationship between model fit and the accuracy…
Adherence to evidence-based recommendations for acute myocardial infarction (AMI) remains unsatisfactory. Quantifying association between using an electronic AMI order set (AMI-OS) and hospital processes and outcomes. Retrospective cohort study. Twenty-one community hospitals. A total of 5879 AMI patients were hospitalized…
Randomized controlled trial evidence supports a restrictive strategy of red blood cell (RBC) transfusion, but significant variation in clinical transfusion practice persists. Patient characteristics other than hemoglobin levels may influence the decision to transfuse RBCs and explain some of this…
To define a quantitative stratification algorithm for the risk of early-onset sepsis (EOS) in newborns ? 34 weeks' gestation. We conducted a retrospective nested case-control study that used split validation. Data collected on each infant included sepsis risk at birth…
The increased vulnerability of late preterm infants is no longer a novel concept in neonatology, with many studies documenting excess morbidity and mortality in these infants during the birth hospitalization. Because outcomes related to gestational age constitute a continuum, it…
Patients with severe sepsis without shock or tissue hypoperfusion face substantial mortality; however, treatment guidelines are lacking. To evaluate the association between intravenous fluid resuscitation, lactate clearance, and mortality in patients with "intermediate" lactate values of 2 mmol/L or greater…
Immunoprophylaxis is the only pharmaceutical intervention for mitigating respiratory syncytial virus (RSV) infection. Patient level data on adherence to American Academy of Pediatrics (AAP) immunoprophylaxis recommendations are limited. This study characterizes adherence to AAP guidelines in privately insured and Medicaid…
Prior studies demonstrate the suitability of natural language processing (NLP) for identifying pneumonia in chest radiograph (CXR) reports, however, few evaluate this approach in intensive care unit (ICU) patients. From a total of 194,615 ICU reports, we empirically developed a…
Respiratory syncytial virus (RSV) infection in infancy is associated with subsequent recurrent wheezing. A retrospective cohort study examined children born at ?32 weeks gestation between 1996-2004. All children were enrolled in an integrated health care delivery system in Northern California…
OBJECTIVE: Using a comprehensive inpatient electronic medical record, we sought to develop a risk-adjustment methodology applicable to all hospitalized patients. Further, we assessed the impact of specific data elements on model discrimination, explanatory power, calibration, integrated discrimination improvement, net reclassification…
RATIONAL, AIMS AND OBJECTIVES: The study aims to determine the extent to which the addition of post-admission information via time-dependent covariates improved the ability of a survival model to predict the daily risk of hospital death. METHOD: Using administrative and…
PURPOSE OF REVIEW: Neonatal early-onset sepsis (EOS) is a very low-incidence, but potentially fatal condition among term and late preterm newborns. EOS algorithms based on risk-factor threshold values result in evaluation and empiric antibiotic treatment of large numbers of uninfected…
OBJECTIVE: Risk adjustment is essential in evaluating the performance of an ICU; however, assigning scores is time-consuming. We sought to create an automated ICU risk adjustment score, based on the Simplified Acute Physiology Score 3, using only data available within…
BACKGROUND: Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions. DESIGN, SETTING, PATIENTS: Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival…
BACKGROUND: Patients with intensive care unit (ICU) transfers from hospital wards have higher mortality than those directly admitted from the emergency department. OBJECTIVE: To describe the association between the timing of unplanned ICU transfers and hospital outcomes. DESIGN, SETTING, PATIENTS:…
OBJECTIVE: To examine the risk and etiology of preterm delivery in women with polycystic ovary syndrome (PCOS). STUDY DESIGN: Retrospective cohort study comparing preterm delivery rate among non-diabetic PCOS and non-PCOS women with singleton pregnancy. Multivariable logistic regression was used…
BACKGROUND: Patient safety remains a national priority, but the role of disease-specific characteristics in safety is not well characterized. METHODS: We identified potentially preventable medical injuries using patient safety indicators (PSIs) and annual data from the Nationwide Inpatient Sample between…
OBJECTIVE: The objectives of this study are to determine immunization rates at discharge from the neonatal intensive care unit (NICU) among infants 2 months of age and above and to evaluate risk factors for underimmunization. STUDY DESIGN: A retrospective cohort…
OBJECTIVE: Moderately premature infants, defined here as those born between 30(0)/(7) and 34(6)/(7) weeks gestation, comprise 3.9% of all births in the United States and 32% of all preterm births. Although long-term outcomes for these infants are better than for…
OBJECTIVE: The objective of this study is to determine the prevalence of placenta previa among different racial and ethnic groups. STUDY DESIGN: We conducted a retrospective cohort study to examine the prevalence of placenta previa among five major racial and…
OBJECTIVES: We examined whether interpersonal processes of care (IPC) were associated with cesarean delivery. METHODS: We performed a cross-sectional study of 1308 postpartum women at Kaiser Permanente Medical Center in Walnut Creek, CA (KP-WC), and San Francisco General Hospital (SFGH)…
BACKGROUND: Bronchiolitis is common in the first two years of life and is the most frequent cause of hospitalization in this age group. No previous studies have used an episode-of-care analysis to describe the frequency, duration, and predictors of bronchiolitis…
OBJECTIVE: To describe the incidence and predictors of total serum bilirubin (TSB) levels that meet or exceed American Academy of Pediatrics (AAP) exchange transfusion (ET) thresholds in the setting of universal screening. STUDY DESIGN: We conducted a retrospective cohort analysis…
BACKGROUND: Ward patients who experience unplanned transfer to intensive care units have excess morbidity and mortality. OBJECTIVE: To develop a predictive model for prediction of unplanned transfer from the medical-surgical ward to intensive care (or death on the ward in…
OBJECTIVE: To develop a quantitative model to estimate the probability of neonatal early-onset bacterial infection on the basis of maternal intrapartum risk factors. METHODS: This was a nested case-control study of infants born at >/=34 weeks' gestation at 14 California…
BACKGROUND: There is little epidemiologic evidence to assess the maturation of respiratory control in premature infants. OBJECTIVE: To measure the success rate or the percentage of infants who have no additional events of various apnea- or bradycardia-free intervals after correcting…
BACKGROUND: As electronic patient data from automated hospital databases become increasingly available, it is important to explore the ways in which these data could be used for the purposes other than patient care, such as quality assurance and improvement. OBJECTIVE:…
OBJECTIVE: To examine the clinical significance of elevated conjugated bilirubin (CB) levels in newborns. STUDY DESIGN: This retrospective study evaluated a birth cohort of 271 186 full-term newborns born within a Northern California hospital network from 1995 to 2004. All…
OBJECTIVE: Apnea of prematurity is one of the most common diagnoses in the NICU. Because resolution of apnea is a usual precondition for discharge from the hospital, different monitoring practices might affect length of stay for premature infants. Our objective…
BACKGROUND: Bronchiolitis has the highest incidence rate of any lower respiratory infection among infants and children /=41 weeks' GA. Bronchiolitis hospitalization, younger chronologic age, prematurity, and RSV season were associated with RSV testing in a multivariate model controlling for other…
BACKGROUND: A complete blood count (CBC) with white blood cell differential is commonly ordered to evaluate newborns at risk for sepsis. OBJECTIVES: To quantify how well components of the CBC predict sepsis in the first 72 hours after birth. METHODS:…
OBJECTIVE: To quantify the relationship between recurrent wheezing (RW) in the third year of life and respiratory syncytial virus (RSV) infection, prematurity, and neonatal oxygen exposure. DESIGN: Retrospective cohort study linking inpatient, outpatient, and laboratory databases for cohort assembly and…
Multistage models have been effective at describing length of stay (LOS) distributions for diverse patient groups. Our study objective was to determine whether such models could be used for patient groups restricted by diagnosis, severity of illness, or hospital in…
OBJECTIVE: Premature infants have increased health care utilization after initial discharge compared with term infants. Young maternal age has been shown to impact health care utilization among term infants, but little is known about the impact of maternal age on…
OBJECTIVE: Premature infants can experience cardiorespiratory events such as apnea after immunization in the neonatal intensive care unit (NICU). These changes in clinical status may precipitate sepsis evaluations. This study evaluated whether sepsis evaluations are increased after immunizations in the…
BACKGROUND: Length of stay (LOS) is a common measure of hospital resource utilization. Most methods for risk-adjusting LOS are limited by the use of only administrative data. Recent studies suggest that adding automated clinical data to these models improves performance.…
OBJECTIVE: To evaluate and compare the use of 6 different methods for calculating expected mortality rates and standardized mortality ratios (SMRs) when performing interhospital mortality rate comparisons. DESIGN: Retrospective cohort study using actual and simulated hospitalization data to evaluate the…
OBJECTIVE: The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. STUDY DESIGN: This was a retrospective cohort study of all women delivered within a managed care network.…
OBJECTIVE: The objective of this study was to determine whether either hyperbilirubinemia or inpatient phototherapy is associated with increased subsequent outpatient visit rates, a possible effect of the 'vulnerable child syndrome.' METHODS: We compared 3 groups of otherwise well term…
BACKGROUND: Patients who experience intra-hospital transfers to a higher level of care (eg, ward to intensive care unit [ICU]) are known to have high mortality. However, these findings have been based on single-center studies or studies that employ ICU admissions…
OBJECTIVE: Validate risk-adjusted readmission rates as a measure of inpatient quality of care after accounting for outpatient facilities, using premature infants as a test case. STUDY SETTING: Surviving infants born between January 1, 1998 and December 12, 2001 at five…
OBJECTIVE: Moderately preterm infants (30-34(6/7) weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the…
OBJECTIVES: Accurately predicting hospital mortality is necessary to measure and compare patient care. External validation of predictive models is required to truly prove their utility. This study assessed the Kaiser Permanente inpatient risk adjustment methodology for hospital mortality in a…
OBJECTIVE: The goal was to assess the impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use. METHODS: In this retrospective cohort study of 358086 infants of > or =35 weeks and > or =2000 g born between January…
AIM: To report findings about the Motor Performance Checklist (MPC) for 5-year-olds, a simple 12-item instrument for assessing gross and fine motor skills, in a research study of neurodevelopmental outcomes after neonatal events. METHODS: We trained 10 examiners to use…
OBJECTIVES: Our aims were to estimate the efficacy of hospital phototherapy for neonatal jaundice and the number needed to treat to prevent one infant from reaching the exchange transfusion level. METHODS: From a cohort of 281 898 infants weighing >…
OBJECTIVE: To describe the maturation of physiologic milestones in preterm infants born between 24 and 32 weeks' gestational age. METHODS: We abstracted daily physiologic maturity information on 865 infants born at or =32 weeks' gestation in the Northern California Kaiser…
OBJECTIVE: To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs. DATA SOURCES: One thousand four hundred and two premature infants born in the Northern…
OBJECTIVE: To assess the risks of moderate prematurity for cerebral palsy (CP), developmental delay/mental retardation (DD/MR), and seizure disorders in early childhood. STUDY DESIGN: Retrospective cohort study using hospitalization and outpatient databases from the Northern California Kaiser Permanente Medical Care…
This clinical trial compared two brief alcohol use interventions in prenatal clinics: Early Start (ES), a substance-abuse screening and treatment program integrated with prenatal care focused on abstention (n=298), and Early Start Plus (ESP), adding a computerized drink-size assessment tool…
OBJECTIVE: To estimate the effect of phototherapy and other predictors on the risk of total serum bilirubin (TSB) >or= 25 mg/dL in infants with a TSB of 17 to 22.9 mg/dL at age >or= 48 hours. STUDY DESIGN: From a…
OBJECTIVE: The goal was to examine the factors influencing parental satisfaction with neonatal intensive care for moderately premature infants in 10 hospitals in Massachusetts and California. METHODS: A total of 677 infants without major anomalies or chromosomal disorders who were…
OBJECTIVES: Among hospitalized NICU infants, preimmunization apnea is a well-recognized predictor of postimmunization apnea. However, predictors for postimmunization apnea among NICU infants without preimmunization apnea have not been investigated. METHODS: Using a large NICU database in the Northern California Kaiser…
OBJECTIVES: To develop a risk-adjustment methodology that maximizes the use of automated physiology and diagnosis data from the time period preceding hospitalization. DESIGN: : Retrospective cohort study using split-validation and logistic regression. SETTING: Seventeen hospitals in a large integrated health…
OBJECTIVE: To describe the development and assessment of the Abbreviated Fine Severity Score (AFSS), a simplified version of the Pneumonia Severity Index (PSI) suitable for providing risk-adjusted reports to clinicians caring for patients hospitalized with community-acquired pneumonia. STUDY DESIGN: Retrospective…
OBJECTIVE: To determine the effect of race and ethnicity on the use of oral beta-agonists, inhaled beta-agonists, and inhaled corticosteroids to treat respiratory symptoms in former premature infants after controlling for medical conditions, socioeconomic status, and site of outpatient care.…
OBJECTIVE: To evaluate whether physiological trends and interaction terms could enhance predictive ability in a variant of the Richardson Score. METHOD: We conducted a retrospective cohort study using data from 2,222 newborns of 34 weeks or more gestation with respiratory…
OBJECTIVE: To determine the long-term outcome of neonatal dehydration. STUDY DESIGN: We identified 182 newborns who were rehospitalized with dehydration (weight loss > or =12% of birth weight and/or serum sodium > or =150 mEq/L) and 419 randomly selected controls…
AIMS/HYPOTHESIS: Gestational diabetes mellitus (GDM) is a risk factor for perinatal complications. In several countries, the criteria for the diagnosis of GDM have been in flux, the American Diabetes Association (ADA) thresholds recommended in 2000 being lower than those of…
OBJECTIVE: We sought to estimate when rates of maternal pregnancy complications increase beyond 37 weeks of gestation. STUDY DESIGN: We designed a retrospective cohort study of all low-risk women delivered beyond 37 weeks' gestational age from 1995 to 1999 within…
OBJECTIVE: The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants. DESIGN/METHODS: In a…
Heavy drinking during pregnancy can cause birth defects and other alcohol-related effects. Because costs associated with fetal complications are high, health care organizations are invested in finding ways to intervene with pregnant drinkers. We describe a computerized intervention tested at…
BACKGROUND: Newborns of 30-34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants. OBJECTIVE: To measure in-hospital outcomes and readmission…
BACKGROUND: The neurodevelopmental risks associated with high total serum bilirubin levels in newborns are not well defined. METHODS: We identified 140 infants with neonatal total serum bilirubin levels of at least 25 mg per deciliter (428 micromol per liter) and…
BACKGROUND: The purpose of this study is to characterize variations in management late preterm infants because such variations in such a large group of neonates would have economic and health implications. METHODS: Comparison of the use of illustrative management approaches…
BACKGROUND: Newborns who are 35 to 36 weeks gestation comprise 7.0% of all live births and 58.3% of all premature infants in the United States. They have been studied much less than very low birth weight infants. OBJECTIVE: To examine…
OBJECTIVE: To compare gestational age at discharge between infants born at 30-34(+6) weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. DESIGN: Prospective observational cohort study. SETTING: Fifty four United…
OBJECTIVE: Gestational weight gain consistent with the Institute of Medicine's recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre-pregnancy factors, pregnancy-related health conditions, and modifiable pregnancy factors on the risks of…
OBJECTIVE: To assess how observational studies on neonatal sepsis can help define the knowledge base required for neonatal randomized, clinical trials. DESIGN: Methodologic review of past observational studies and critical reviews. RESULTS: Observational studies on neonatal sepsis have suffered from…
OBJECTIVE: To examine temporal trends in the rates of severe bronchopulmonary dysplasia (BPD) between 1994 and 2002. STUDY DESIGN: In a retrospective cohort study, all infants with a gestational age (GA)
The prevalence of motor examination abnormalities among a general pediatric population is unknown. We determined the frequency of motor abnormalities noted at five years of age during a neurologic examination by a child neurologist. As part of a follow-up study…
OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), women's target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women…
AIM: To analyse rehospitalisation of newborns of all gestations. METHODS: A total of 33,276 surviving infants of all gestations born between 1 October 1998 and 31 March 2000 at seven Kaiser Permanente Medical Care Program (KPMCP) delivery services were studied…
OBJECTIVES: (1) To validate a previously reported risk index for predicting total serum bilirubin (TSB) levels of 25 mg/dL (428 micromol/L) or higher; (2) to combine a subset of this index with TSB levels measured at less than 48 hours…
Background: Voluntary reporting systems identify only a fraction of medical errors. Electronic identification mechanisms, which are more efficient, have been defined for adverse drug events. However, similar systems are lacking for other types of errors. Objective: The investigators sought to…
OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy. DESIGN: Observational cohort. SETTING/PARTICIPANTS: Pregnant women from 1 of 6 sites in the San Francisco area (N=1,809). MEASUREMENTS AND MAIN RESULTS:…
BACKGROUND: Despite extensive evaluation, our understanding of risk factors for premature delivery is incomplete. OBJECTIVE: To examine whether a woman's health status and risk factors before pregnancy are associated with a woman's risk of preterm delivery, independent of risk factors…
OBJECTIVES: To develop a model to predict which newborns >/=34 weeks gestation with respiratory distress will die or will require prolonged (>3 days) assisted ventilation. METHODS: Retrospective cohort study using data from Northern California newborns >/=34 weeks gestation who presented…
OBJECTIVE: Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications. METHOD: Live births (146,526) were identified between 1995 and 1999 in the Kaiser Permanente Medical Care…
OBJECTIVE: Risk factors for perinatal arterial stroke (PAS) are poorly understood. Most previous studies lack an appropriate control group and include only infants with symptoms in the newborn period. We set out to determine prenatal and perinatal risk factors for…
OBJECTIVE: To describe rates and identify risk factors for rehospitalization during the first year of life among infants with bronchopulmonary dysplasia (BPD). STUDY DESIGN: This was a retrospective cohort study of infants born at a gestational age (GA)
CONTEXT: Half of all cases of cerebral palsy (CP) occur in term infants, for whom risk factors have not been clearly defined. Recent studies suggest a possible role of chorioamnionitis. OBJECTIVE: To determine whether clinical chorioamnionitis increases the risk of…
OBJECTIVE: The purpose of this study was to determine whether rates of hypertensive disorders of pregnancy increase beyond 37 weeks of gestation and to address how best to analyze these rates. STUDY DESIGN: This was a retrospective cohort study of…
OBJECTIVE: Breastfeeding rates fall short of goals set in Healthy People 2010 and other national recommendations. The current, national breastfeeding continuation rate of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this…
OBJECTIVE: To describe the incidence, etiology, treatment, and outcome of newborns with total serum bilirubin (TSB) levels >or=30 mg/dL (513 micro mol/L). DESIGN: Population-based case series. SETTING: Eleven Northern California Kaiser Permanente Medical Care Program hospitals and 1 affiliated hospital.…
OBJECTIVE: In 1994, the American Academy of Pediatrics (AAP) published a practice guideline with age-specific thresholds for phototherapy for healthy term newborns with hyperbilirubinemia. The purpose of this study was to examine adherence to the guideline in a large managed…
OBJECTIVE: To evaluate the effect of Early Start, a managed care organization's obstetric clinic-based perinatal substance abuse treatment program, on neonatal outcomes. STUDY DESIGN: Study subjects were 6774 female Kaiser Permanente members who delivered babies between July 1, 1995 and…
OBJECTIVE: To investigate the significance of jaundice noted in the first 24 hours after birth in a community setting. DESIGN: Supplementary analyses of a nested case-control study. SETTING: Northern California Kaiser Permanente Medical Care Program. PATIENTS: Six hundred thirty-one randomly…
OBJECTIVES: To determine the incidence of neonatal dehydration leading to rehospitalization, whether clinical and health services data could predict its occurrence, and the outcome of dehydrated infants. METHODS: We employed a retrospective case-control design nested within a cohort of 51…
OBJECTIVE: Short postpartum stays are common. Current guidelines provide scant guidance on how routine follow-up of newly discharged mother-infant pairs should be performed. We aimed to compare 2 short-term (within 72 hours of discharge) follow-up strategies for low-risk mother-infant pairs…
Neonatal intensive care is extremely expensive; there is both a financial and an ethical obligation to practice efficiently. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under pressure to find strategies for…
OBJECTIVES: Illness severity scores for newborns are complex and restricted by birth weight and have dated validations and calibrations. We developed and validated simplified neonatal illness severity and mortality risk scores. The primary outcome was in-hospital mortality. STUDY DESIGN: Thirty…
Maternal substance abuse is a serious problem with significant adverse effects to mothers, fetuses, and children. The Early Start Program provides pregnant women in a managed care organization with screening and early identification of substance abuse problems, early intervention, ongoing…
OBJECTIVE: To investigate biological and health services predictors of extreme neonatal hyperbilirubinemia in a health maintenance organization. DESIGN: Nested case-control study. SETTING: Eleven Northern California Kaiser Permanente hospitals. SUBJECTS: The cohort consisted of 51,387 newborns born at 36 weeks or…
BACKGROUND: Few data are available on the outcome of neonatal sepsis evaluations in an era when intrapartum antibiotic therapy is common. METHODS: We identified all newborns weighing >/=2000 g at birth who were ever evaluated for suspected bacterial infection at…
BACKGROUND: Recently enacted federal legislation mandates insurance coverage of at least 48 hours of postpartum hospitalization, but most mothers and newborns in the United States will continue to go home before the third postpartum day. National guidelines recommend a follow-up…
OBJECTIVES: Reference data are lacking on the frequency and duration of assisted ventilation in neonates. This information is essential for determining resource needs and planning clinical trials. As mortality becomes uncommon, ventilator utilization is increasingly used as a measure for…
OBJECTIVE: To determine the frequency and interhospital variation of bilirubin testing and identified hyperbilirubinemia in a large health maintenance organization. DESIGN: Retrospective cohort study. SETTING: Eleven Northern California Kaiser Permanente hospitals. SUBJECTS: A total of 51,387 infants born in 1995-1996…
OBJECTIVES: New interventions to prevent respiratory syncytial virus (RSV) have recently become available. Clinical decisions about the use of these interventions require a better understanding of the incidence of and risk factors for RSV. We sought to characterize the epidemiology…
OBJECTIVES: To evaluate the costs and benefits of two new agents, respiratory syncytial virus immune globulin (RSVIG) and palivizumab, to prevent respiratory syncytial virus (RSV) infection among premature infants discharged from the neonatal intensive care unit (NICU) before the start…
BACKGROUND: High-risk newborns are known to have higher than average utilization of services after discharge from the neonatal intensive care unit (NICU). Most studies on this subject report aggregate data over periods ranging from 1 to 3 years postdischarge. Little…
OBJECTIVES: To estimate the cost and health benefits of implementing a risk factor-based prevention strategy for early-onset neonatal group B streptococcal (GBS) disease, using baseline assumptions and costs from a health maintenance organization. With the risk factor-based strategy, intrapartum antibiotics…
'Rule out sepsis' may be the most common discharge diagnosis among infants admitted to the neonatal intensive care unit. Although the frequency of sepsis, meningitis, and other confirmed bacterial infections has remained constant (between 1 and 5/1000 live births) for…
BACKGROUND: Postpartum hospital stays seem likely to remain limited even under new laws which mandate that insurers cover 48-hour hospitalization after uncomplicated delivery. Clinicians, who are increasingly practicing in capitated arrangements, need better information to maximize clinical benefit to mothers…
We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neonatal care and make recommendations on how neonatal mortality rates (NMRs) could be used in quality improvement efforts. Deaths were…
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