Assessing the Ambulatory Surgery Center Volume-Outcome Association

Improved robotic-assisted cardiac surgery outcomes with greater hospital volume: a national representative cohort analysis of 10,543 cardiac surgery surgeries

Robot-assisted surgical techniques have enhanced surgical precision, control, stability, and vision, particularly in cardiac interventions. However, the relationship between hospital volume and the clinical and readmission outcomes of robot-assisted cardiac surgery remains undefined. This retrospective cohort study analyzed Nationwide Readmissions Database (NRD) data from 2010 to 2020. Patients who underwent various cardiac procedures were categorized into three groups based on hospital volume of robot-assisted cardiac surgery: low-volume centers (LVCs), medium-volume centers (MVCs), and high-volume centers (HVCs). Our primary outcome variables of interest were the incidence of perioperative complications, 30-day readmission, and in-hospital mortality. 10,543 patients were included in the analysis. Compared with those treated in LVCs, the adjusted OR of 30-day readmission [OR, 0.70; (95% CI 0.53-0.92), P = 0.014] was lower in HVCs. However, higher perioperative bleeding rates were observed in MVCs (OR, 1.38; (95% CI 1.14-1.66), P = 0.001) and HVCs (OR, 1.84; (95% CI 1.52-2.21), P = 0.001). No significant differences were found in in-hospital mortality. Our research demonstrated that higher hospital surgical volume was associated with better outcomes in robot-assisted cardiac surgery, despite higher perioperative bleeding rates.

Patient Characteristics and Procedural Volume at an Overseas Military Treatment Facility Emergency Department: Effects of the COVID-19 Pandemic and Implications on Clinical Skill Sustainment

INTRODUCTION

Future conflicts against near-peer competitors require proficient physicians to mitigate operational morbidity and mortality. Recent literature suggests that current patient demographics and staffing models may not sustain the combat care skills of military physicians. However, skill sustainment at overseas military treatment facilities located within foreign countries has not been examined. This article investigates patient characteristics and procedural performance rates within the U.S. Naval Hospital Okinawa Emergency Department (USNHO-ED), providing novel insight into the skill sustainment provided to U.S. Military physicians stationed in a foreign country.

MATERIALS AND METHODS

An automated retrospective chart review of patients triaged within the USNHO-ED from January 2018 to June 2022 was performed. Patient census, emergency severity index (ESI) triage scores, patient disposition, and procedures of interest were recorded. Procedures of interest included: "endotracheal intubation," "arterial line placement," "central line placement," "dislocation reduction," "procedural sedation," "cardioversion," "thoracostomy," "blood product transfusion," "lumbar puncture," "paracentesis," "arthrocentesis," and "joint injection." Monthly procedure rates and procedure rates per 1,000 patients were calculated. Procedure rates for individual physicians with greater than 500 patient encounters were calculated. Variation in patient characteristics and procedural rates during the COVID-19 pandemic was investigated.

RESULTS

The USNHO-ED triaged 128,696 patients and performed 865 procedures of interest during the study period. In total, 5,020 patients were triaged as ESI 1/2, 34,179 patients were triaged as ESI 3, and 89,499 patients were triaged as ESI 4/5. A total of 122,881 patients were discharged from the emergency department. The procedures performed most often were procedural sedation (4.02 per month, 2.06 per 1,000 patients), dislocation reduction (3.41 per month, 1.75 per 1,000 patients), lumbar puncture (1.94 per month, 0.99 per 1,000 patients), and endotracheal intubation (1.21 per month, 0.62 per 1,000 patients). All other procedures were performed less than once per month and 0.5 instances per 1,000 patients. Over half of physicians with at least 500 encounters did not perform a blood product transfusion, thoracostomy, central line placement, arterial line placement, cardioversion, or paracentesis. Rates for many procedures were lower than those seen at civilian institutions. During the COVID-19 pandemic, the daily census was lower, patients were more often triaged to higher ESI 1-3, and the admission rate was higher. Procedural sedations per month, as well as procedural sedations, dislocation reductions, and blood product transfusions per 1,000 patients, increased during the COVID-19 pandemic. No other temporal procedural variation occurred. Pediatric patients were more often triaged to ESI 4/5, more likely to be discharged, more likely to undergo procedural sedation, and less likely to undergo endotracheal intubation, blood product transfusion, thoracostomy, central line placement, cardioversion, or joint invasive procedures.

CONCLUSIONS

This study demonstrates a low patient volume, patient acuity, and procedural performance rate for physicians at USNHO-ED. The inability of military physicians stationed in foreign locations to leverage the local civilian market further reduces their ability to maintain operational readiness. In combination, these hindrances degrade physician readiness, creating significant risk in the ability to support warfighters engaged in combat operations. Unique staffing models and partnerships must be developed to maintain the proficiency of overseas military physicians.

Ambulatory knee arthroscopic surgery yields cost savings and improved health outcomes

PURPOSE

This study measured the health-related quality of life (HRQoL) and costs and conducted a cost-utility analysis and budget impact analysis of ambulatory knee arthroscopic surgery compared with inpatient knee arthroscopic surgery in Thailand from a societal perspective.

METHODS

Health outcomes were measured in units of quality-adjusted life year (QALY) based on the Thai version of the EQ-5D-5L Health Questionnaire, and costs were obtained from an electronic database at a tertiary care hospital (Ramathibodi Hospital). A cost-utility analysis was performed to evaluate ambulatory and inpatient surgery using the societal perspective and a 2-week time horizon. The incremental cost-effectiveness ratio was applied to examine the costs and QALYs. One-way sensitivity analysis was used to investigate the robustness of the model. Budget impact analysis was performed considering over 5 years.

RESULTS

A total of 161 knee arthroscopic patients were included and divided into two groups: ambulatory surgery (58 patients) and inpatient surgery (103 patients). The total cost of the inpatient surgery was 2235 United States dollars (USD), while the ambulatory surgery cost was 2002 USD. The QALYs of inpatient surgery and ambulatory surgery were 0.79 and 0.81, respectively, resulting in the ambulatory surgery becoming a dominant strategy (cost reduction of 233 USD with an increase of 0.02 QALY) over the inpatient surgery. The ambulatory surgery led to net savings of 4.5 million USD over 5 years. Medical supply costs are one of the most influential factors affecting the change in results.

CONCLUSION

Ambulatory knee arthroscopic surgery emerged as a cost-saving strategy over inpatient surgery, driven by lower treatment costs and enhanced HRQoL. Budget impact analysis indicated net savings over 5 years, supporting the feasibility of adopting ambulatory knee arthroscopic surgery. Our findings were advocated for its application across diverse hospitals and informed policymakers to improve reimbursement systems in low- to middle-income countries and Thailand.

LEVEL OF EVIDENCE

Level IV.