Identification of in-hospital complications from claims data. Is it valid?

Rate of Emergency Lower Extremity Amputations in the United States Among Medicare Beneficiaries

OBJECTIVE

To determine the rate of emergency versus elective lower extremity amputations in the United States.

BACKGROUND

Lower extremity amputation is a common endpoint for patients with poorly controlled diabetes and multilevel peripheral vascular disease. Although the procedure is ideally performed electively, patients with limited access may present later and require an emergency operation. To what extent rates of emergency amputation for lower extremities vary across the United States is unknown.

METHODS

Evaluation of Medicare beneficiaries who underwent lower extremity amputation between 2015 and 2020. The rate was determined for each zip code and placed into rank order from lowest to highest rate. We merged each beneficiary's place of residence and location of care with the American Hospital Association Annual Survey using Google Maps Application Programming Interface to determine the travel distance for patients to undergo their procedure.

RESULTS

Of 233,084 patients, 66.3% (154,597) were men, 69.8% (162,786) were White. The average age (SD) was 74 years (8). There was wide variation in rates of emergency lower extremity amputation. The lowest quintile of zip codes demonstrated an emergency amputation rate of 3.7%, whereas the highest quintile demonstrated 90%. The median travel distance in the lowest emergency surgery rate quintile was 34.6 miles compared with 10.5 miles in the highest quintile of emergency surgery ( P < 0.001).

CONCLUSIONS

There is wide variation in the rate of emergency lower extremity amputations among Medicare beneficiaries, suggesting variable access to essential vascular care. Travel distance and rate of amputation have an inverse relationship, suggesting that barriers other than travel distance are playing a role.

Association of county-level food deserts and food swamps on postoperative outcomes among patients undergoing colorectal surgery

BACKGROUND

Although malnutrition has been linked to worse healthcare outcomes, the broader context of food environments has not been examined relative to surgical outcomes. We sought to define the impact of food environment on postoperative outcomes of patients undergoing resection for colorectal cancer (CRC).

METHODS

Patients who underwent surgery for CRC between 2014 and 2020 were identified from the Medicare database. Patient-level data were linked to the United States Department of Agriculture data on food environment. Multivariable regression was used to examine the association between food environment and the likelihood of achieving a textbook outcome (TO). TO was defined as the absence of an extended length of stay (≥75th percentile), postoperative complications, readmission, and mortality within 90 days.

RESULTS

A total of 260,813 patients from 3017 counties were included in the study. Patients from unhealthy food environments were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with higher social vulnerability (all P < .01). Patients residing in unhealthy food environments were less likely to achieve a TO than that of patients residing in the healthiest food environments (food swamp: 48.8% vs 52.4%; food desert: 47.9% vs 53.7%; P < .05). On multivariable analysis, individuals residing in the unhealthy food environments had lower odds of achieving a TO than those of patients living in the healthiest food environments (food swamp: OR, 0.86; 95% CI, 0.83-0.90; food desert: OR, 0.79; 95% CI, 0.76-0.82); P < .05).

CONCLUSION

The surrounding food environment of patients may serve as a modifiable sociodemographic risk factor that contributes to disparities in postoperative CRC outcomes.

Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions

Importance

Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes.

Objective

To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes.

Design, Setting, and Participants

This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023.

Exposure

Health insurance status (private insurance, Medicaid, or no insurance).

Main Outcomes and Measures

The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay.

Results

The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001).

Conclusions and Relevance

Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.

Clinical implications of frailty assessed in hospitalized patients with acute-exacerbation of interstitial lung disease

BACKGROUND

Approximately 50% of patients with interstitial lung disease (ILD) experience frailty, which remains unexplored in acute exacerbations of ILD (AE-ILD). A better understanding may help with prognostication and resource planning. We evaluated the association of frailty with clinical characteristics, physical function, hospital outcomes, and post-AE-ILD recovery.

METHODS

Retrospective cohort study of AE-ILD patients (01/2015-10/2019) with frailty (proportion ≥0.25) on a 30-item cumulative-deficits index. Frail and non-frail patients were compared for pre- and post-hospitalization clinical characteristics, adjusted for age, sex, and ILD diagnosis. One-year mortality, considering transplantation as a competing risk, was analysed adjusting for age, frailty, and Charlson Comorbidity Index (CCI).

RESULTS

89 AE-ILD patients were admitted (median: 67 years, 63% idiopathic pulmonary fibrosis). 31 were frail, which was associated with older age, greater CCI, lower 6-min walk distance, and decreased independence pre-hospitalization. Frail patients had more major complications (32% vs 10%, p = .01) and required more multidisciplinary support during hospitalization. Frailty was not associated with 1-year mortality (HR: 0.97, 95%CI: [0.45-2.10]) factoring transplantation as a competing risk.

CONCLUSIONS

Frailty was associated with reduced exercise capacity, increased comorbidities and hospital complications. Identifying frailty may highlight those requiring additional multidisciplinary support, but further study is needed to explore whether frailty is modifiable with AE-ILD.

Association of Health Professional Shortage Area Hospital Designation With Surgical Outcomes and Expenditures Among Medicare Beneficiaries

OBJECTIVE

To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to nonshortage area designated hospitals among Medicare beneficiaries.

BACKGROUND

More than a quarter of Americans live in federally designated Health Professional Shortage Areas. Although there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas.

METHODS

Cross-sectional retrospective study from 2014 to 2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. We assessed risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the 4 operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments.

RESULTS

Patients (mean age=75.6 years, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be White (84.6% vs 88.4%, P <0.001) and less likely to have≥2 Elixhauser comorbidities (75.5% vs 78.2%, P <0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05% vs 6.69%, odds ratio=0.90, CI, 0.90-0.91, P <0.001) and readmission (14.99% vs 15.74%, odds ratio=0.94, CI, 0.94-0.95, P <0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than nonshortage designated hospitals ($28,517 vs $29,685, difference= -$1168, P <0.001).

CONCLUSIONS

Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these underserved communities are considered.

Index hospital cost of adverse events following thoracic surgery: a systematic review of economic literature

OBJECTIVES

Adverse events (AEs) following thoracic surgery place considerable strain on healthcare systems. A rigorous evaluation of the economic impact of thoracic surgical AEs remains lacking and is required to understand the value of money of formal quality improvement initiatives. Our objective was to conduct a systematic review of all available literature focused on specific cost of postoperative AEs following thoracic surgery.

DESIGN

Systematic review of the economic literature was performed, following recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

An economic search filter developed by the Canadian Agency for Drugs and Technologies in Health was applied, and MEDLINE, Embase and The Cochrane Library were searched from inception to January 2022.

ELIGIBILITY CRITERIA

We included English articles involving adult patients who underwent a thoracic surgical procedure with estimated costs of postoperative complications. Eligible study designs included comparative observational studies, randomised control trials, decision analytic or cost-prediction models, cost analyses, cost or burden of illness studies, economic evaluation studies and systematic reviews and/or meta-analyses of cost analyses and cost of illness studies.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles and abstracts in the first stage and full-text articles of included studies in the second stage. Disagreements during abstract and full-text screening stages were resolved via discussion until a consensus was reached. Studies were appraised for methodological quality using the Critical Appraisal Skills Program checklist.

RESULTS

3349 studies were identified: 20 met inclusion criteria. Most were conducted in the USA (12/20), evaluating AE impact on hospital expenditures (18/20). 68 procedure-specific AE mean costs were characterised (USD$). The most commonly described were anastomotic leak (mean:range) (USD$49 278:$6 176-$133 002) and pneumonia ($12 258:$2608-$34 591) following esophagectomy, and prolonged air leak ($2556:$571-$3573), respiratory failure ($19 062:$11 841-$37 812), empyema ($30 189:$23 784-$36 595), pneumonia ($15 362:$2542-$28 183), recurrent laryngeal nerve injury ($16 420:$4224-$28 616) and arrhythmia ($6835:$5833-$8659) following lobectomy.

CONCLUSIONS

Hospital costs associated with AEs following thoracic surgery are substantial and varied. Quantifying costs of AEs enable future economic evaluation studies, which could help prioritising value-directed quality improvement to optimally improve outcomes and reduce costs.

Surgical Procedures at Critical Access Hospitals Within Hospital Networks

OBJECTIVE

To compare surgical outcomes and expenditures at critical access hospitals that do versus do not participate in a hospital network among Medicare beneficiaries.

BACKGROUND

Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some critical access hospitals have gone further to formally participate in a hospital network.

METHODS

This was a cross-sectional retrospective study from 2014 to 2018 comparing 16,128 Medicare beneficiary admissions for appendectomy, cholecystectomy, colectomy, or hernia repair at critical access hospitals that do versus do not participate in a hospital network. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and postacute care payments.

RESULTS

Beneficiaries (average age = 75.7 years, SD = 7.4) who obtained care at critical access hospitals in a hospital network were more likely to carry ≥2 Elixhauser comorbidities (68.7% vs. 62.8%, P < 0.001). Rates of 30-day mortality were higher at critical access hospitals in a hospital network (4.30% vs. 3.81%, OR = 1.11, P < 0.001). Similarly, readmission rates were higher at critical access hospitals that were in a hospital network (15.13% vs. 14.34%, OR = 1.06, P < 0.001). Additionally, total episode payments were found to be $960 higher per patient at critical access hospitals that were in a hospital network ($23,878 vs. $22,918, P < 0.001).

CONCLUSIONS

Critical access hospitals within hospital networks provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas

PURPOSE

Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures.

METHODS

We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care.

FINDINGS

Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively.

CONCLUSIONS

Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

Association of Neighborhood Deprivation, Race, and Postoperative Outcomes: Improvement in Neighborhood Deprivation is Associated With Worsening Surgical Disparities

INTRODUCTION

While there is a broad understanding that patient factors, hospital characteristics, and an individual's neighborhoods all contribute to the observed disparities, the relationship between these factors remains unclear. The purpose of this study was to evaluate the association of neighborhood deprivation improve postoperative outcomes for White and Black Medicare beneficiaries equally.

METHODS

We performed a cross-sectional Retrospective cohort study from 2014 to 2018 of 1372,487 White and Black Medicare beneficiaries aged 65 and older who underwent an inpatient colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair. We compared postoperative complications, readmission, and mortality by race across neighborhood deprivation. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods Area Deprivation Index; a modern-day measure of neighborhood disadvantage that includes education, employment, housing quality, and poverty measures.

RESULTS

Overall, 1372,487 Medicare beneficiaries with mean age 72.1 years, 50.3% female, 91.2% White, residing in 1107,051 unique neighborhoods underwent 1 of 5 operations. The proportion of Black beneficiaries was 6.5% within the lowest deprivation neighborhoods and increased to 16.9% within the highest deprivation neighborhoods ( P <0.001). The interaction between beneficiary neighborhood and race demonstrated that the association of neighborhood on outcomes varied by race. Specifically, White beneficiaries had 1.5% absolute mortality decrease from the highest to lowest deprivation neighborhoods [odds ratio (OR):1.32, 95% confidence interval (CI): 1.27-1.38; P <0.001], whereas Black beneficiaries had a 0.72% absolute mortality decrease from the highest to lowest deprivation neighborhoods (OR: 1.13, 95% CI: 1.02-1.24; P =0.018). Similarly, White beneficiaries had 3.6% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.23, 95% CI: 1.21-1.28; P <0.001) while Black beneficiaries had a 1.2%% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.07, 95% CI: 1.01-1.13; P =0.017). For 30-day readmission rates, White beneficiaries realized a 2.3% absolute decrease from the highest to lowest deprivation neighborhoods (OR: 1.19, 95% CI: 1.02-1.24; P <0.001), whereas Black beneficiaries saw no change (OR: 1.03, 95% CI: 0.97-1.10; P =0.269).

CONCLUSIONS AND RELEVANCE

Lower neighborhood deprivation is associated with improved outcomes across both White and Black Medicare beneficiaries; however, improvement in neighborhood deprivation disproportionately favored White beneficiaries. These findings provide a cautionary example of the misperception of the protective effect of higher social class for Black patients and provide a cautionary example that improvements in neighborhoods may have disparate health impact on its members.

Disparities in unplanned surgery amongst medicare beneficiaries

BACKGROUND

While significant efforts have been made to understand surgical disparities for procedures that are performed in either the elective or unplanned settings, far less is known about procedures performed in both settings.

METHODS

Cross-sectional study of 1,135,743 Medicare beneficiaries undergoing incisional hernia repair, colectomy, or abdominal aortic aneurysm repair between 2014 and 2018. Risk-adjusted outcomes were assessed using multivariable logistic regression.

RESULTS

Compared to White beneficiaries, unplanned surgery rates were higher for Black (44.0%vs38.8%, OR = 1.29,p < 0.001) and Asian beneficiaries(40.4%vs38.8%,OR = 1.09,p < 0.001). While there were minimal differences in 30-day mortality for elective procedures, unplanned procedures demonstrated wider disparities (Black vs White 12.4%vs11.3%,OR = 1.11,p < 0.001; Asian vs White 13.2%vs11.3%,OR = 1.18,p < 0.001). Similar patterns were observed for readmissions.

CONCLUSIONS

Unplanned procedures are more common and demonstrate wider disparities in outcomes among minority Medicare beneficiaries. Reducing unplanned surgery rates among these groups may be an effective strategy to limit overall disparities in postoperative outcomes.

Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study

Background and Aims

The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade.

Material and Methods

This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018.

Results

A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006).

Conclusion

The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.

Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients

PURPOSE

Nearly half of all Medicare beneficiaries are enrolled in privatized Medicare insurance plans (Medicare Advantage [MA]). Little comparative information is available about access, outcomes, and cost of inpatient cancer surgery between MA and Traditional Medicare (TM) beneficiaries. We set out to assess and compare access, postoperative outcomes, and estimated cost of inpatient cancer surgery among MA and TM beneficiaries.

METHODS

Retrospective cohort analysis of MA or TM beneficiaries undergoing elective inpatient cancer surgery (for cancers located in lung, esophagus, stomach, pancreas, liver, colon, or rectum) was performed using the Office of Statewide Health Planning Inpatient Database linked to California Cancer Registry from 2000 to 2020. For each cancer site, risk-standardized access to high-volume hospitals, postoperative 30-day mortality, complications, failure to rescue, and surgery-specific estimated costs were compared between MA and TM beneficiaries.

RESULTS

This analysis of 76,655 Medicare beneficiaries (median age 74 years, 51% female, 39% MA) included 31,913 colectomies, 10,358 proctectomies, 4,604 hepatectomies, 2,895 pancreatectomies, 3,639 gastrectomies, 1,555 esophagectomies, and 21,691 lung resections. Except for colon surgery, MA beneficiaries were less likely to receive care at a high-volume hospital. Mortality was significantly higher among MA beneficiaries (v TM) for gastrectomy (adjusted risk difference [ARD], 1.5%; 95% CI, 0.01 to 2.9; P = .036), pancreatectomy (ARD, 2.0%; CI, 0.80 to 3.3; P = .002), and hepatectomy (ARD, 1.4%; 95% CI, 0.1 to 2.9; P = .04). By contrast, compared with TM, MA beneficiaries incurred lower estimated hospital costs.

CONCLUSION

Enrollment in MA plan is associated with lower estimated hospital costs. However, compared with TM, MA beneficiaries had lower access to high-volume hospitals and increased 30-day mortality for stomach, pancreas, or liver surgery.

Development and validation of risk-adjusted quality indicators for the long-term outcome of acute sepsis care in German hospitals based on health claims data

Background

Methods for assessing long-term outcome quality of acute care for sepsis are lacking. We investigated a method for measuring long-term outcome quality based on health claims data in Germany.

Materials and methods

Analyses were based on data of the largest German health insurer, covering 32% of the population. Cases (aged 15 years and older) with ICD-10-codes for severe sepsis or septic shock according to sepsis-1-definitions hospitalized in 2014 were included. Short-term outcome was assessed by 90-day mortality; long-term outcome was assessed by a composite endpoint defined by 1-year mortality or increased dependency on chronic care. Risk factors were identified by logistic regressions with backward selection. Hierarchical generalized linear models were used to correct for clustering of cases in hospitals. Predictive validity of the models was assessed by internal validation using bootstrap-sampling. Risk-standardized mortality rates (RSMR) were calculated with and without reliability adjustment and their univariate and bivariate distributions were described.

Results

Among 35,552 included patients, 53.2% died within 90 days after admission; 39.8% of 90-day survivors died within the first year or had an increased dependency on chronic care. Both risk-models showed a sufficient predictive validity regarding discrimination [AUC = 0.748 (95% CI: 0.742; 0.752) for 90-day mortality; AUC = 0.675 (95% CI: 0.665; 0.685) for the 1-year composite outcome, respectively], calibration (Brier Score of 0.203 and 0.220; calibration slope of 1.094 and 0.978), and explained variance (R ² = 0.242 and R ² = 0.111). Because of a small case-volume per hospital, applying reliability adjustment to the RSMR led to a great decrease in variability across hospitals [from median (1st quartile, 3rd quartile) 54.2% (44.3%, 65.5%) to 53.2% (50.7%, 55.9%) for 90-day mortality; from 39.2% (27.8%, 51.1%) to 39.9% (39.5%, 40.4%) for the 1-year composite endpoint]. There was no substantial correlation between the two endpoints at hospital level (observed rates: ρ = 0, p = 0.99; RSMR: ρ = 0.017, p = 0.56; reliability-adjusted RSMR: ρ = 0.067; p = 0.026).

Conclusion

Quality assurance and epidemiological surveillance of sepsis care should include indicators of long-term mortality and morbidity. Claims-based risk-adjustment models for quality indicators of acute sepsis care showed satisfactory predictive validity. To increase reliability of measurement, data sources should cover the full population and hospitals need to improve ICD-10-coding of sepsis.

Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries

BACKGROUND

Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery.

STUDY DESIGN

This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation).

RESULTS

Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes.

CONCLUSIONS

National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.

Skilled Nursing Facility Quality Rating and Surgical Outcomes Following Coronary Artery Bypass Grafting

Centers for Medicare and Medicaid Services created a 5-star quality rating system to evaluate skilled nursing facilities (SNFs). Patient discharge to lower-star quality SNFs has been shown to adversely impact surgical outcomes. Recent data has shown that over 20% of patients are discharged to an SNF after CABG, but the link between SNF quality and CABG outcomes has not been established. The purpose of this study is to evaluate the impact of SNF quality ratings on postoperative outcomes after CABG. Retrospective cohort review of Medicare patients undergoing CABG and discharged to an SNF between the years 2016-2017. Patients were categorized into 3 groups according to the star rating of the SNF with receipt of care after discharge (ie, below average, average, above average). Risk-adjusted 30-day to 1-year outcomes of mortality, readmission, and SNF length of stay were calculated and compared using multivariable logistic regression and Poisson models across SNF quality categories. Of the 73,164 Medicare patients in our sample, 15,522 (21.2%) were discharged to an SNF. Patients in below average SNFs were more likely to be younger, Black, Medicare/Medicaid dual eligible, and have more comorbidities. Compared to above average SNFs, patients discharged to below average SNFs experienced higher risk-adjusted 30-day mortality (2.1% vs 1.6%, P<0.02), readmission (21.6% vs 19.3%, P<0.01) and SNF length of stay (17.3d vs 16.5d, P<0.0001). Within 90-days, below average SNFs experienced higher risk-adjusted readmission rates (31.7% vs 30.0%, P<0.004). Outcomes at 1-year were not statistically significant. Medicare beneficiaries discharged to lower quality SNFs experienced worse postoperative outcomes after CABG. Identifying best practices at high performing SNFs, to potentially implement at low performing facilities, may improve equitable care for patients.

The win ratio: A novel approach to define and analyze postoperative composite outcomes to reflect patient and clinician priorities

BACKGROUND

The "win ratio" (WR) is a novel statistical technique that hierarchically weighs various postoperative outcomes (eg, mortality weighted more than complications) into a composite metric to define an overall benefit or "win." We sought to use the WR to assess the impact of social vulnerability on the likelihood of achieving a "win" after hepatopancreatic surgery.

METHODS

Individuals who underwent an elective hepatopancreatic procedure between 2013 and 2017 were identified using the Medicare database, which was merged with the Center for Disease Control and Prevention's Social Vulnerability Index. The win ratio was defined based on a hierarchy of postoperative outcomes: 90-day mortality, perioperative complications, 90-day readmissions, and length of stay. Patients matched based on procedure type, race, sex, age, and Charlson Comorbidity Index score were compared and assessed relative to win ratio.

RESULTS

Among 32,557 Medicare beneficiaries who underwent hepatectomy (n = 11,621, 35.7%) or pancreatectomy (n = 20,936, 64.3%), 16,846 (51.7%) patients were male with median age of 72 years (interquartile range 68-77) and median Charlson Comorbidity Index of 3 (interquartile range 2-8), and a small subset of patients were a racial/ethnic minority (n = 3,759, 11.6%). Adverse events associated with lack of a postoperative optimal outcome included 90-day mortality (n = 2,222, 6.8%), postoperative complication (n = 8,029, 24.7%), readmission (n = 6,349, 19.5%), and length of stay (median: 7 days, interquartile range 5-11). Overall, the patients from low Social Vulnerability Index areas were more likely to "win" with a textbook outcome (win ratio 1.07, 95% confidence interval 1.01-1.12) compared with patients from high social vulnerability counties; in contrast, there was no difference in the win ratio among patients living in average versus high Social Vulnerability Index (win ratio 1.04, 95% confidence interval 0.98-1.10). In assessing surgeon volume, patients who had a liver or pancreas procedure performed by a high-volume surgeon had a higher win ratio versus patients who were treated by a low-volume surgeon (win ratio 1.21, 95% confidence interval 1.16-1.25). In contrast, there was no difference in the win ratio (win ratio 1.01, 95% confidence interval 0.97-1.06) among patients relative to teaching hospital status.

CONCLUSION

Using a novel statistical approach, the win ratio ranked outcomes to create a composite measure to assess a postoperative "win." The WR demonstrated that social vulnerability was an important driver in explaining disparate postoperative outcomes.

Emergency Surgery Rates Among Medicare Beneficiaries With Access Sensitive Surgical Conditions

INTRODUCTION

Access sensitive surgical conditions should be treated electively with optimal access but result in emergency operations when access is limited. However, the rates of emergency procedures for these conditions are unknown.

METHODS

Cross-sectional retrospective review of Medicare beneficiaries who underwent access sensitive surgical procedures (abdominal aortic aneurysm repair, colectomy for colorectal cancer, or incisional hernia repair) between 2014 and 2018. Risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, and Elixhauser comorbidities), hospital characteristics (ownership, size, geographic region, surgical volume) and type of operation were compared between planned and emergency (urgent and emergent) surgical procedures. Outcome measures were rates of emergency procedures as well as associated postoperative outcomes.

RESULTS

Of the 744,818 Medicare beneficiaries undergoing access sensitive surgical procedures, 259,541 (34.9%) were done in the emergency setting. Risk-adjusted rates of emergency surgery varied widely across hospital service areas from 23.28% (lowest decile) to 54.88% (highest decile) (Odds Ratio 4.74; P < 0.001). Emergency procedures were associated with significantly higher rates of 30-d mortality (8.15% versus 3.65%, P < 0.001) and readmissions (16.28% versus 12.88%, P < 0.001) compared to elective procedures. Sensitivity analysis with younger and healthier beneficiaries demonstrated persistently high rates (23.3%) of emergency surgery with wide regional variation and worse patient outcomes.

CONCLUSIONS

Emergency surgery for access sensitive surgical conditions is extremely common and varied almost fivefold across United States hospital service areas. This suggests there are opportunities to improve access for these common surgical conditions.

A novel machine learning approach to identify social risk factors associated with textbook outcomes after surgery

BACKGROUND

Identifying social determinants of health has become a priority for many researchers, health care providers, and payers. The vast amount of patient and population-level data available on social determinants creates, however, both an opportunity and a challenge as these data can be difficult to synthesize and analyze.

METHODS

Medicare beneficiaries who underwent 1 of 4 common operations between 2013 and 2017 were identified. Using a machine learning algorithm, the primary independent variable, surgery social determinants of health index, was derived from 15 common, publicly available social determents of health measures. After development of a surgery social determinants of health index, multivariable logistic regression was used to estimate the association of this index with textbook outcomes, as well as the component metrics of textbook outcomes.

RESULTS

A novel surgery social determinants of health index was developed with factor component weights that varied relative to their impact on postoperative outcomes. Factors with the highest weight in the algorithm relative to postoperative outcomes were the proportion of noninstitutionalized civilians with a disability and persons without high school diploma, while components with the lowest weights were the proportion of households with more people than rooms and persons below poverty. Overall, an increase in surgery social determinants of health index was associated with 6% decreased odds (95% confidence interval: 0.93-0.94) of achieving a textbook outcome. In addition, an increase in surgery social determinants of health index was associated with increased odds of each of the individual components of textbook outcome; ranging from 3% increased odds (95% confidence interval: 1.03-1.04) for 90-day readmission to 10% increased odds (95% confidence interval: 1.09-1.11) for 90-day mortality. Further, there was 6% increased odds (95% confidence interval: 1.05-1.07) of experiencing a complication and 7% increased odds (95% confidence interval: 1.06-1.07) of having an extended length of stay. Minority patients from a high surgery social determinants of health index had 38% lower odds (95% confidence interval: 0.60-0.65) of achieving a textbook outcome compared with White/non-Hispanic patients from a low surgery social determinants of health index area.

CONCLUSION

Using a machine learning approach, we developed a novel social determents of health index to predict the probability of achieving a textbook outcome after surgery.

Social Vulnerability And Outcomes For Access-Sensitive Surgical Conditions Among Medicare Beneficiaries

Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.

Increased Intraoperative Faculty Entrustment and Resident Entrustability Does Not Compromise Patient Outcomes After General Surgery Procedures

BACKGROUND

Intraoperative resident autonomy has been compromised secondary to expectations for increased supervision without defined parameters for safe progressive independence, diffusion of training experience, and more to learn with less time. Surgical residents who are insufficiently entrusted during training attain less autonomy, confidence, and even clinical competency, potentially affecting future patient outcomes.

OBJECTIVE

To determine if OpTrust, an educational intervention for increasing intraoperative faculty entrustment and resident entrustability, negatively impacts patient outcomes after general surgery procedures.

METHODS

Surgical faculty and residents received OpTrust training and instruction to promote intraoperative faculty entrustment and resident entrustability. A post-intervention OpTrust cohort was compared to historical and pre-intervention OpTrust cohorts. Multivariable logistic and negative binomial regression was used to evaluate the impact of the OpTrust intervention and time on patient outcomes.

SETTING

Single tertiary academic center.

PARTICIPANTS

General surgery faculty and residents.

MAIN OUTCOMES AND MEASURES

Thirty-day postoperative outcomes, including mortality, any complication, reoperation, readmission, and length of stay.

RESULTS

A total of 8890 surgical procedures were included. After risk adjustment, overall patient outcomes were similar. Multivariable regression estimating the effect of the OpTrust intervention and time revealed similar patient outcomes with no increased risk (P > 0.05) of mortality {odds ratio (OR), 2.23 [95% confidence interval (CI), 0.87-5.6]}, any complication [OR, 0.98 (95% CI, 0.76-1.3)], reoperation [OR, 0.65 (95% CI, 0.42-1.0)], readmission [OR, 0.82 (95% CI, 0.57-1.2)], and length of stay [OR, 0.99 (95% CI, 0.86-1.1)] compared to the historic and pre-intervention OpTrust cohorts.

CONCLUSIONS

OpTrust, an educational intervention to increase faculty entrustment and resident entrustability, does not compromise postoperative patient outcomes. Integrating faculty and resident development to further enhance entrustment and entrustability through OpTrust may help facilitate increased resident autonomy within the safety net of surgical training without negatively impacting clinical outcomes.

Impact of the COVID-19 pandemic on non-COVID-19 hospital mortality in patients with schizophrenia: a nationwide population-based cohort study

It remains unknown to what degree resource prioritization toward SARS-CoV-2 (2019-nCoV) coronavirus (COVID-19) cases had disrupted usual acute care for non-COVID-19 patients, especially in the most vulnerable populations such as patients with schizophrenia. The objective was to establish whether the impact of the COVID-19 pandemic on non-COVID-19 hospital mortality and access to hospital care differed between patients with schizophrenia versus without severe mental disorder. We conducted a nationwide population-based cohort study of all non-COVID-19 acute hospitalizations in the pre-COVID-19 (March 1, 2019 through December 31, 2019) and COVID-19 (March 1, 2020 through December 31, 2020) periods in France. We divided the population into patients with schizophrenia and age/sex-matched patients without severe mental disorder (1:10). Using a difference-in-differences approach, we performed multivariate patient-level logistic regression models (adjusted odds ratio, aOR) with adjustment for complementary health insurance, smoking, alcohol and substance addiction, Charlson comorbidity score, origin of the patient, category of care, intensive care unit (ICU) care, major diagnosis groups and hospital characteristics. A total of 198,186 patients with schizophrenia were matched with 1,981,860 controls. The 90-day hospital mortality in patients with schizophrenia increased significantly more versus controls (aOR = 1.18; p < 0.001). This increased mortality was found for poisoning and injury (aOR = 1.26; p = 0.033), respiratory diseases (aOR = 1.19; p = 0.008) and for both surgery (aOR = 1.26; p = 0.008) and medical care settings (aOR = 1.16; p = 0.001). Significant changes in the case mix were noted with reduced admission in the ICU and for several somatic diseases including cancer, circulatory and digestive diseases and stroke for patients with schizophrenia compared to controls. These results suggest a greater deterioration in access to, effectiveness and safety of non-COVID-19 acute care in patients with schizophrenia compared to patients without severe mental disorders. These findings question hospitals' resilience pertaining to patient safety and underline the importance of developing specific strategies for vulnerable patients in anticipation of future public health emergencies.

Cancer and Pregnancy: National Trends

OBJECTIVE

Cancer and pregnancy are likely increasing; however, updated estimates are needed to optimally address the unique needs of this patient population. The study aims to estimate the prevalence of cancer and cancer survivorship at delivery, to test the change in odds of cancer and cancer survivorship at delivery over the 10-year period, and to compare medical conditions, serious events, and obstetric complications between pregnancies with and without cancer at delivery.

STUDY DESIGN

We conducted a retrospective analysis of the National Inpatient Sample (NIS), the largest all-payer inpatient health database in the United States. We identified delivery admissions from 2004 to 2013 with a concurrent diagnosis of cancer using International Classification of Disease, ninth revision (ICD-9) codes. Multivariable logistic regression was used to test the change in prevalence of concurrent cancer, cancer survivorship, and pregnancy and to compare outcomes between deliveries with and without cancer. All analyses were adjusted for NIS-provided population weights and strata.

RESULTS

During the study period, the NIS represented a national estimate of 40,855,208 deliveries. The odds of cancer increased from 3.41/10,000 deliveries in 2004 to 4.33/10,000 in 2013. This trend was statistically significant, including after adjustment for maternal age (adjusted odds ratio [aOR] = 1.03 [95% confidence interval (CI): 1.01-1.04]). Cancer survivorship at delivery increased significantly (aOR = 1.07 [95% CI: 1.06-1.08]). Women with cancer more often experienced one or more of the following: death, ventilation, cardiac arrest, sepsis, or acute respiratory or renal failure during delivery (aOR for composite outcome 10.7 [95% CI: 6.6-17.2]), even after adjustment in a multivariable logistic regression model.

CONCLUSION

The odds of cancer and cancer survivorship at delivery increased from 2004 to 2013, independent of maternal age. Women with cancer were more likely to experience medical or obstetric complications during their delivery compared with women without cancer. These findings highlight the importance of obstetric and oncologic clinical and research collaboration to improve patient care.

KEY POINTS

· The odds of cancer at delivery increased.. · Women with cancer may have delivery complications.. · Cancer survivorship at delivery increased..

Evolving Factors in Hospital Safety: A Systematic Review and Meta-Analysis of Hospital Adverse Events

OBJECTIVE

This study aimed to estimate the frequency of hospital adverse events (AEs) and explore the rate of AEs over time, and across and within hospital populations.

METHODS

Validated search terms were run in MEDLINE and EMBASE; gray literature and references of included studies were also searched. Studies of any design or language providing an estimate of AEs within the hospital were eligible. Studies were excluded if they only provided an estimate for a specific AE, a subgroup of hospital patients or children. Data were abstracted in duplicate using a standardized data abstraction form. Study quality was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis estimated the occurrence of hospital AEs, and meta-regression explored the association between hospital AEs, and patient and hospital characteristics.

RESULTS

A total of 45,426 unique references were identified; 1,265 full-texts were reviewed and 94 studies representing 590 million admissions from 25 countries from 1961 to 2014 were included. The incidence of hospital AEs was 8.6 per 100 patient admissions (95% confidence interval [CI], 8.3 to 8.9; I2 = 100%, P < 0.001). Half of the AEs were preventable (52.6%), and a third resulted in moderate/significant harm (39.7%). The most evaluated AEs were surgical AEs, drug-related AEs, and nosocomial infections. The occurrence of AEs increased by year (95% CI, -0.05 to -0.04; P < 0.001) and patient age (95% CI = -0.15 to -0.14; P < 0.001), and varied by country income level and study characteristics. Patient sex, hospital type, hospital service, and geographical location were not associated with AEs.

CONCLUSIONS

Hospital AEs are common, and reported rates are increasing in the literature. Given the increase in AEs over time, hospitals should reinvest in improving hospital safety with a focus on interventions targeted toward the more than half of AEs that are preventable.

Impact of hospital quality on surgical outcomes in patients with high social vulnerability: Association of textbook outcomes and social vulnerability by hospital quality

BACKGROUND

We sought to define the impact of high- versus low-quality hospitals on the risk of adverse outcomes among patients undergoing hepatopancreatic surgery relative to social vulnerability. Social vulnerability is an important factor associated with risk of adverse postoperative outcomes.

METHODS

Patients from 2013 to 2017 were identified from the Medicare Inpatient Standard Analytic File. Hospital quality was determined by calculating risk-adjusted probability to achieve a textbook outcome. The Social Vulnerability Index was used to categorize patients. Risk-adjusted probability of mortality, morbidity, and textbook outcome was examined across varying social vulnerability indices stratified by low-, average-, and high-quality hospitals.

RESULTS

Among 27,000 patients who underwent a pancreatectomy (67%) or hepatectomy (33%%), median patient age was 72 years, 48% were female, and 89% were White; mean Social Vulnerability Index was 49. Risk-adjusted 90-day mortality (odds ratio: 1.32, 95% CI: 1.20-1.59, P = .004) and postoperative complications (odds ratio: 1.12, 95% confidence interval: 1.00-1.24, P = .044) were both higher among beneficiaries from the highest social vulnerability counties versus the lowest counties. At low-quality hospitals, patients from the highest vulnerability counties had 70% higher odds of mortality (odds ratio: 1.70, 95% confidence interval: 1.16-2.48, P = .007), 31% higher odds of overall morbidity odds ratio: 1.31, 95% confidence interval: 1.05-2.63, P = .013), and 19% lower odds of achieving a textbook outcome (odds ratio: 0.81, 95% confidence interval: 0.66-0.99, P = .035)-all of which were markedly worse compared with outcomes achieved at high-quality hospitals.

CONCLUSION

Among patients with increased social vulnerability, outcomes were considerably better at high-quality hospitals. Referral of socially vulnerable patients to high-quality hospitals represents an important opportunity to ensure optimal outcomes after complex surgery.

Outcomes of inpatient cholecystectomy among adults with cystic fibrosis in the United States

BACKGROUND

Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis (CF) and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use. Cholecystectomy may be considered, but the outcomes of cholecystectomy are not well described among modern patients with CF.

AIM

To determine the risk profile of inpatient cholecystectomy in patients with CF.

METHODS

The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF. A propensity weighted sample was selected that closely matched patient demographics, patient’s individual comorbidities, and hospital characteristics. The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy. Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF.

RESULTS

A total of 1239 inpatient cholecystectomies were performed in patients with CF, of which 78.6% were performed laparoscopically. Mortality was < 0.81%, similar to those without CF (P = 0.719). In the propensity weighted analysis of laparoscopic cholecystectomy, there was no difference in mortality, or pulmonary or surgical complications between patients with CF and controls. After adjusting for significant covariates among patients with CF, open cholecystectomy was independently associated with a 4.8 d longer length of stay (P = 0.018) and an $18449 increase in hospital costs (P = 0.005) compared to laparoscopic cholecystectomy.

CONCLUSION

Patients with CF have a very low mortality after cholecystectomy that is similar to the general population. Among patients with CF, laparoscopic approach reduces resource utilization and minimizes post-operative complications.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE

To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon.

BACKGROUND

Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons.

METHODS

We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days.

RESULTS

We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01).

CONCLUSION

Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Intersection of social vulnerability and residential diversity: Postoperative outcomes following resection of lung and colon cancer

INTRODUCTION

While the impact of demographic factors on postoperative outcomes has been examined, little is known about the intersection between social vulnerability and residential diversity on postoperative outcomes following cancer surgery.

METHODS

Individuals who underwent a lung or colon resection for cancer were identified in the 2016-2017 Medicare database. Data were merged with the Centers for Disease Control and Prevention social vulnerability index and a residential diversity index was calculated. Logistic regression models were utilized to estimate the probability of postoperative outcomes.

RESULTS

Among 55 742 Medicare beneficiaries who underwent lung (39.4%) or colon (60.6%) resection, most were male (46.6%), White (90.2%) and had a mean age of 75.3 years. After adjustment for competing risk factors, both social vulnerability and residential diversity were associated with mortality and other postoperative outcomes. In assessing the intersection of social vulnerability and residential diversity, synergistic effects were noted as patients from counties with low social vulnerability and high residential diversity had the lowest probability of 30-day mortality (3.2%, 95% confidence interval [CI]: 3.0-3.5) while patients from counties with high social vulnerability and low diversity had a higher probability of 30-day postoperative death (5.2%, 95% CI: 4.6-5.8; odds ratio: 1.02, 95% CI: 1.01-1.03).

CONCLUSION

Social vulnerability and residential diversity were independently associated with postoperative outcomes. The intersection of these two social health determinants demonstrated a synergistic effect on the risk of adverse outcomes following lung and colon cancer surgery.

Rural hospitals are not associated with worse postoperative outcomes for colon cancer surgery

PURPOSE

We sought to determine whether colorectal cancer surgery can be done safely at rural hospitals. The current study compared outcomes among rural patients who underwent colon resection at rural and nonrural hospitals.

METHODS

Medicare beneficiaries who underwent colon resection for cancer between 2013 and 2017 were identified using the Medicare Inpatient Standard Analytic Files. Patients and hospitals were designated as rural based on rural-urban continuum codes. Risk-adjusted postoperative outcomes and hospitalization spending were compared among patients undergoing resection at rural versus nonrural hospitals.

RESULTS

Among 3,937 patients who resided in a rural county and underwent colon resection for cancer, mean age was 76.3 (SD: 7.1) years and 1,432 (36.4%) patients underwent operative procedure at a rural hospital. On multivariable analyses, no differences in postoperative outcomes were noted among Medicare beneficiaries undergoing colon resection for cancer at nonrural versus rural hospitals. Specifically, the risk-adjusted probability of experiencing a postoperative complication at a nonrural hospital was 15.4% (95% CI: 14.1%-16.8%) versus 16.3% (95% CI: 14.2%-18.3%) at a rural hospital (OR 1.08, 95% CI: 0.85-1.38); 30-day mortality (nonrural: 2.9%, 95% CI: 2.2-3.6 vs rural: 3.5%, 95% CI: 2.4-4.5) was also comparable. In addition, price standardized, risk-adjusted expenditures were similar at nonrural ($18,610, 95% CI: $18,037-$19,183) and rural ($19,010, 95% CI: $18,630-$19,390) hospitals.

CONCLUSION

Among rural Medicare beneficiaries who underwent a colon resection for cancer, there were no differences in postoperative outcomes among nonrural versus rural hospitals. These findings serve to highlight the importance of policies and practice guidelines that secure safe, local surgical care, allowing rural clinicians to accommodate strong patient preferences while delivering high-quality surgical care.

Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission

BACKGROUND

Discharge against medical advice may be associated with more readmissions.

OBJECTIVE

To evaluate DAMA in patients with acute ischemic stroke (AIS) and identify the relationship between DAMA and 30-day unplanned readmissions.

DESIGN

A retrospective cohort study.

PARTICIPANTS

The National Readmission Database was used to identify inpatients with a primary diagnosis of AIS who were either discharged home or DAMA between 2010 and 2017 in the USA.

MEASURES

Demographic features, hospital type, comorbidities, stroke risk factors, severity indices, and treatments were compared between patients discharged routinely and DAMA. Multivariable logistic regression was used to evaluate predictors of DAMA, and a double robust inverse probability of treatment weighting method was used to assess the association between DAMA and 30-day unplanned readmissions.

KEY RESULTS

Overall, 1,335,484 patients with AIS were included, of whom 2.09% (n = 27,892) were DAMA. The prevalence of DAMA in AIS patients increased from 1.65 in 2010 to 2.57% in 2017. The rates of 30-day unplanned readmissions for DAMA and non-DAMA patients were 16.81% and 7.78%, respectively. Patients with drug abuse, alcohol abuse, smoking, prior stroke, psychoses, and intravenous thrombolysis had greater odds of DAMA. DAMA was associated with all-cause readmissions (OR, 2.04; 95% CI, 2.01-2.07) and remained a strong predictor for transient ischemic attack/stroke-specific and cardiac-specific causes of readmissions.

CONCLUSIONS

Although the DAMA rate is low in AIS patients, DAMA is a risk factor for all-cause and recurrent stroke-specific readmissions. Future studies are needed to address issues around compliance and engagement with health care to reduce DAMA.

Association of social vulnerability with the use of high-volume and Magnet recognition hospitals for hepatopancreatic cancer surgery

BACKGROUND

In an effort to improve perioperative and oncologic outcomes, there have been multiple quality improvement initiatives, including regionalization of high-risk procedures and hospital accreditation designations from independent organizations. These initiatives may, however, hinder access to high-quality surgical care for certain patients living in areas with high social vulnerability who may be disproportionally affected, leading to disparities in access and worse postoperative outcomes.

METHODS

Medicare beneficiaries who underwent liver or pancreas resection for cancer were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals were designated as high-volume based on Leapfrog criteria. The Centers for Disease Control and Prevention's social vulnerability index database was used to abstract social vulnerability index information based on each beneficiary's county of residence at the time of operation. The probability that a patient received care at a high-volume hospital stratified by the social vulnerability of the patient's county of residence was examined. Risk-adjusted postoperative outcomes were compared across low, average, and high levels of vulnerability at both low- and high-volume hospitals.

RESULTS

Among 16,978 Medicare beneficiaries who underwent a pancreatectomy (n = 13,393, 78%) or a liver resection (n = 3,594, 21.2%) for cancer, the mean age was 73.3 years (standard deviation: 5.8), nearly half the cohort was female (n = 7,819, 46%), and the overwhelming majority were White (n = 15,034, 88.5%). Mean social vulnerability index was 49.8 (standard deviation 24.8) and mean Charlson comorbidity index was 4.8 (standard deviation: 3). Overall, 8,251 (48.6%) of patients had their operations at a high-volume hospital, and 3,802 patients had their operations at a hospital with Magnet recognition. Age and sex were similar within the low-, average-, and high-social vulnerability index cohorts (P > .05); however, race differed across social vulnerability index groups. White patients made up 93% (n = 3,241) of the low social vulnerability index compared with 83.9% (n = 2,706) of the high-social vulnerability index group, whereas non-Whites made up 7% (n = 244) of the low-social vulnerability index group compared with 16.1% (n = 556) of the high-social vulnerability index group (P < .001). The risk-adjusted overall probability of having surgery at a high-volume hospital decreased as social vulnerability increased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Risk-adjusted probability of postoperative complications increased with social vulnerability index; however, among patients with high social vulnerability, risk of postoperative complications was lower at high-volume hospitals compared with low-volume hospitals. In contrast, there was no difference in postoperative complications between hospitals with and without Magnet recognition across social vulnerability index.

CONCLUSION

Patients residing in communities characterized by a high social vulnerability index were less likely to undergo high-risk cancer surgery at a high-volume hospital. Although postoperative complications and mortality increased as social vulnerability index increased, some of the risk appeared to be mitigated by having surgery at a high-volume hospital. These data highlight the importance of access to high-quality surgical care, especially among patients who may already be more vulnerable.

Population-based analysis of cost and peri-operative outcomes between open and robotic primary retroperitoneal lymph node dissection for germ cell tumors

PURPOSE

To compare perioperative outcomes and perform the first cost analysis between open retroperitoneal lymph node dissection (O-RPLND) and Robotic-RPLND (R-RPLND) using a national all-payer inpatient care database.

METHODS

Nationwide Inpatient Sample (NIS) was queried between 2013-2016 for primary RPLND and germ cell tumor. We compared cost, length of stay (LOS), and complications between O-RPLND and R-RPLND. Linear regression plots identified point of cost equivalence between R-RPLND and O-RPLND. A multivariable linear regression model was generated to analyze predictors of cost.

RESULTS

44 cases of R-RPLND and 319 cases of O-RPLND were identified. R-RPLND was associated with lower rate of complications (0% vs. 16.6%, p < 0.01) and shorter LOS [Median (IQR): 1.5 (1-3) days vs. 4 (3-6) days, p < 0.01]. Rates of ileus, genitourinary complications, and transfusions were lower with R-RPLND, but did not reach significance. On multivariable analysis, robotic approach independently contributed $4457, while each day of hospitalization contributed to an additional $2,431 to the overall model of cost. Linear regression plots determined point of cost equivalence between an R-RPLND staying a mean of 2 days was 4-5 days for O-RPLND, supporting the multivariable analysis. Total hospitalization cost was equivalent between R-RPLND and O-RPLND [Median (IQR): $15,681($12,735-$21,596) vs $16,718($11,799-$24,403), p = 0.48]-suggesting that the cost equivalency of R-RPLND is, at least in part, attributable to shorter LOS.

CONCLUSION

While O-RPLND remains the gold standard and this study is limited by selection bias of a robotic approach to RPLND, our findings suggest primary R-RPLND may represent a cost-equivalent option with decreased hospital LOS in select cases.

Potential Selection Bias in Observational Studies Comparing Cervical Disc Arthroplasty to Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study using a national administrative database.

OBJECTIVE

To define the cohort differences in patient characteristics between patients undergoing cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) in a large national sample, and to describe the impact of those baseline patient characteristics on analyses of costs and complications.

SUMMARY OF BACKGROUND DATA

CDA was initially studied in high quality, randomized trials with strict inclusion criteria. Recently a number of non-randomized, observational studies have been published an attempt to expand CDA indications. These trials are predisposed to falsely attributing differences in outcomes to an intervention due to selection bias.

METHODS

Adults undergoing ACDF or CDA between 2004 and 2014 were identified using International Classification of Diseases, 9, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. Perioperative demographics, comorbidities, complications, and costs were queried. Patient characteristics were compared via chi-square and t tests. Cost, mortality, and complications were compared between ACDF and CDA cohorts using models that adjusted for demographics and comorbidities, as well as "naïve" models that did not.

RESULTS

A total of 290,419 procedures, 98.2% ACDF and 1.8% CDA, were included in the sample. Compared with ACDF patients, CDA patients were younger, healthier as evidenced by number of comorbidities, and had an improved socioeconomic status as measured by income and insurance. The naïve logistic regression model showed that hospital costs for CDA were $549 lower than ACDF. In the fully specified model, CDA was $574 more expensive. The naïve model for medical complications suggests a protective advantage for CDA over ACDF, odds ratio of 0.627, P < 0.01. No statistically significant difference was found in the fully specified model in terms of complications.

CONCLUSION

Patients undergoing CDA were younger and healthier with higher socioeconomic statuses compared with ACDF patients. Accounting for these baseline differences significantly attenuated the apparent benefit for CDR on costs and medical complications.

LEVEL OF EVIDENCE

3.

Cannabis Abuse or Dependence and Post-operative Outcomes After Appendectomy and Cholecystectomy

BACKGROUND

Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy.

METHODS

Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample.

RESULTS

The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates.

CONCLUSIONS

Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.

Symptomatic human immunodeficiency virus-infected patients have poorer outcomes following emergency general surgery: A study of the nationwide inpatient sample

BACKGROUND

The impact of human immunodeficiency virus (HIV) infection on outcomes following common emergency general surgery procedures has not been evaluated since the widespread introduction of highly active antiretroviral therapy.

METHODS

A retrospective cohort study was conducted using the Nationwide Inpatient Sample. Records of patients who underwent laparoscopic or open appendectomy, cholecystectomy, or colon resection after emergency admission from 2004 to 2011 were obtained. Outcomes analyzed included in-hospital mortality, length of stay, total charges, and selected postoperative complications. Patients were divided among three groups, HIV-negative controls, asymptomatic HIV-positive patients, and symptomatic HIV/acquired immune deficiency syndrome (AIDS) patients. Data were analyzed using χ and multivariable regression with propensity score matching among the three groups, with p value less than 0.05 significant.

RESULTS

There were 974,588 patients identified, of which 1,489 were HIV-positive and 1,633 were HIV/AIDS-positive. The HIV/AIDS patients were more likely to die during their hospital stay than HIV-negative patients (4.4% vs. 1.6%, adjusted odds ratio, 3.53; 95% confidence interval [CI], 2.67-4.07; p < 0.001). The HIV/AIDS patients had longer hospital stays (7 days vs. 3 days; adjusted difference, 3.66 days; 95% CI, 3.53-4.00; p < 0.001) and higher median total charges than HIV-negative patients (US $47,714 vs. US $28,405; adjusted difference, US $15,264; 95% CI, US $13,905-US $16,623; p < 0.001). The HIV/AIDS patients also had significantly increased odds of certain postoperative complications, including sepsis, septic shock, pneumonia, urinary tract infection, acute renal failure and need for transfusion (p < 0.05 for each). Differences persisted irrespective of case complexity and over the study period. Asymptomatic HIV-positive patients had outcomes similar to HIV-negative patients.

CONCLUSION

The HIV/AIDS patients have a greater risk of death, infectious, and noninfectious complications after emergency surgery regardless of operative complexity and despite advanced highly active antiretroviral therapy. Patients who have not developed advanced disease, however, have similar outcomes to HIV-negative patients.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Prevalence and Impact of Aphasia among Patients Admitted with Acute Ischemic Stroke

OBJECTIVE

Aphasia is one of the most severe symptoms in stroke patients, affecting one-third of acute stroke patients. We aimed to investigate the prevalence and outcomes of aphasia in patients with acute ischemic stroke (AIS).

METHODS

We computed the weighted prevalence of aphasia in AIS patients using the 2003 to 2014 National Inpatient Sample databases. Crude regression model, multivariable regression model, and propensity score matching were used to evaluate the impact of aphasia on the clinical outcomes in AIS patients. We performed the Subpopulation Treatment Effect Pattern Plot (STEPP) analyses in propensity score matching cohort to visually display the effect of interaction between aphasia and age on the clinical outcomes.

RESULTS

A total of 16.93% of 4,339,156 AIS patients identified were with aphasia. The proportion of patients with comorbid aphasia increased from 13.34% in 2003 to 21.94% in 2014 (P < .0001). The results of both multivariable regression model and propensity score matching analyses indicated aphasia in AIS as a risk factor for in-hospital deaths. Aphasia was linked to prolonged length of stay (0.66 day, P < .0001) and high hospitalization cost ($971.35, P < .0001). In the STEPP analyses, in-hospital mortality rate increased with age, and the rate was higher in patients with aphasia, but the ratios decreased with an increase in age.

CONCLUSIONS

Prevalence of comorbid aphasia with AIS is increasing, and it has a significant impact on clinical outcomes. Additionally, aphasia shows a greater impact on survival and medical burden among young patients with AIS.

Comparing textbook outcomes among patients undergoing surgery for cancer at U. S. News & World Report ranked hospitals

Background

The objective of the current study was to define and compare rates of textbook outcomes (TO) among patients undergoing colorectal, lung, esophagus, liver, and pancreatic surgery for cancer at U.S. News & World Report (USNWR) ranked hospitals.

Methods

Medicare Inpatient Standard Analytic Files 2013‐2015 were utilized to examine the relationship of TO and USNWR hospital ratings following surgery for colorectal, lung, esophageal, pancreatic, and liver cancer. TO was defined as no postoperative surgical complications, no prolonged length of hospital stay, no readmission within 90 days after discharge, and no postoperative mortality within 90 days after surgery.

Results

Among the 35,352 Medicare patients included in the cohort, 16,820 (47.6%) underwent surgery at honor roll hospitals, whereas 18 532 (52.4%) underwent surgery at non‐honor roll hospitals. The overall proportion of patients who achieved TO was 50.1%. In examining the clinical outcomes of patients who underwent surgery, there was no difference in the odds of achieving TO at honor roll vs non‐honor roll hospitals (colorectal: odds ratio [OR], 0.87; 95% confidence interval [CI], 0.69‐1.10; lung: OR, 1.07; 95% CI, 0.87‐1.32; esophagus: OR, 1.44; 95% CI, 0.72‐2.89; liver: OR, 1.27; 95% CI, 0.87‐1.84; pancreas: OR, 1.04; 95% CI, 0.67‐1.62).

Conclusion and Relevance

Patients undergoing surgery for lung, esophageal, liver, pancreatic, and colorectal cancer had comparable rates of TO at honor roll vs non‐honor roll hospitals. No linear association was observed between hospital position in the rank and postoperative outcomes such as TO indicating that patients should not overly focus on the exact position within USNWR ranked hospitals. These data highlight to patients and physicians that up to one‐half of patients undergoing surgery for cancer should anticipate at least one adverse outcome.

Dedicated Cancer Centers are More Likely to Achieve a Textbook Outcome Following Hepatopancreatic Surgery

INTRODUCTION

The aim of the current study is to assess rates of textbook outcome (TO) among Medicare beneficiaries undergoing hepatopancreatic (HP) surgery for cancer at dedicated cancer centers (DCCs) and National Cancer Institute affiliated cancer centers (NCI-CCs) versus non-DCC non-NCI hospitals.

PATIENTS AND METHODS

Medicare Inpatient Standard Analytic Files were utilized to identify patients undergoing HP surgery between 2013 and 2017. TO was defined as no postoperative surgical complications, no 90-day mortality, no prolonged length of hospital stay, and no 90-day readmission after discharge.

RESULTS

Among 21,234 Medicare patients, 8.2% patients underwent surgery at DCCs whereas 32.1% underwent surgery at NCI-CCs and 59.7% underwent an operation at neither DCCs nor NCI-CCs. Although DCCs more often cared for patients with severe comorbidities [Charlson score > 5: DCCs, 1195 (68.9%), NCI-CCs, 3687 (54.1%), others, 3970 (31.3%); p < 0.001], DCCs achieved higher rates of TO compared with NCI-CCs and other US hospitals. Interestingly, DCCs were more likely to perform surgery with a minimally invasive approach versus NCI-CCs and other US hospitals (17.0%, n = 295, vs. 12.6%, n = 856 vs. 11.9%, n = 1504, p < 0.001). On multivariable analysis, patients undergoing liver surgery at DCCs had 31% and 36% higher odds of achieving TO compared with NCI-CCs and other US hospitals, respectively. Medicare expenditure was substantially lower for patients achieving TO at DCCs compared with patients who achieved a TO at NCI-CCs.

CONCLUSIONS

Even though DCCs more frequently took care of patients with high comorbidity burden, the likelihood of achieving TO for HP surgery at DCCs was higher compared with NCI-CCs and other US hospitals. The data suggest that DCCs provide higher-value surgical care for patients with HP malignancies.

CMS Hospital Compare System of Star Ratings and Surgical Outcomes Among Patients Undergoing Surgery for Cancer: Do the Ratings Matter?

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) Hospital Compare star rating system has been proposed as a means to assess hospital quality performance. The current study aimed to investigate outcomes and payments among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer across hospital star rating groups.

METHODS

The Medicare Standard Analytic Files (SAF) from 2013 to 2015 were used to derive the analytic cohort. The association of star ratings to perioperative outcomes and expenditures was examined.

RESULTS

Among 119,854 patients, the majority underwent surgery at a 3-star (n = 34,901, 29.1%) or 4-star (n = 30,492, 25.4%) hospital. Only 12.2% (n = 14,732) were treated at a 5-star hospital. Across all procedures examined, patients who underwent surgery at a 1-star hospital had greater odds of death within 90 days than patients who had surgery at a 5-star hospital (colorectal, 1.41 [95% confidence interval {CI}, 1.25-1.60]; lung, 1.97 [95% CI 1.56-2.48]; esophagectomy, 1.83 [95% CI 0.81-4.16]; pancreatectomy, 1.70 [95% CI 1.20-2.41]; hepatectomy, 1.63 [95% CI 0.96-2.77]). A similar trend was noted for failure to rescue (FTR), with the greatest odds of FTR associated with 1-star hospitals. The median expenditure associated with an abdominal operation was $1661 more at a 1-star hospital than at a 5-star hospital (1-star: $17,399 vs 5-star: $15,738). A similar trend was noted for thoracic operations.

CONCLUSION

The risk of FTR, 90-day mortality, and increased hospital expenditure were all higher at a 1-star hospital. Further research is needed to investigate barriers to care at 5-star-rated hospitals and to target specific interventions to improve outcomes at 1-star hospitals.

Opioid Use Disorders and the Risk of Postoperative Pulmonary Complications

BACKGROUND

As the rate of opioid use disorders continues to rise, perioperative physicians are increasingly faced with the challenge of providing analgesia to these patients after surgery. Due to the likelihood of opioid dose escalation in the perioperative period, we hypothesized that opioid-dependent patients would be at increased risk for postoperative pulmonary complications.

METHODS

A retrospective cross-sectional analysis of patients undergoing 6 representative elective surgical procedures was performed using the Nationwide Inpatient Sample from 2002 to 2011. The primary outcome was a composite including prolonged mechanical ventilation, reintubation, and acute respiratory failure. Secondary outcomes were length of stay, in-hospital mortality, and total hospital costs. Both multivariable logistic regression and propensity score matching were used to determine the impact of opioid use disorder on outcomes.

RESULTS

The total sample-weighted cohort consisted of 7,533,050 patients. Patients with opioid use disorders were more likely to suffer pulmonary complications, with a frequency of 4.2% compared to 1.6% in the nonopioid-dependent group (P < .001), and had a 1.62 times higher odds (95% confidence interval [CI], 1.16-2.27) in multivariable regression analysis. In a secondary subgroup analysis, only patients undergoing a colectomy had a greater odds of suffering pulmonary complications (odds ratio, 2.64; 95% CI, 1.42-4.91; P = .0021). Additionally, patients with an opioid use disorder had a longer length of stay (0.84 days [95% CI, 0.52-1.16; P < .001]) and greater costs ($1816 [95% CI, 935-2698; P < .001]).

CONCLUSIONS

This study demonstrates that patients with opioid use disorders are at increased risk for postoperative pulmonary complications, and have prolonged length of stay and resource utilization. Further research is needed regarding interventions to reduce the risk of complications in this subset of patients.

Comparison of Hospitals Affiliated With PPS-Exempt Cancer Centers, Other Hospitals Affiliated With NCI-Designated Cancer Centers, and Other Hospitals That Provide Cancer Care

IMPORTANCE

Congress has exempted 11 specialized cancer centers in the United States from the Prospective Payment System (PPS). These centers are also exempt from reporting many of the process-of-care and outcome measures to the Centers for Medicare & Medicaid Services that are required for hospitals in the PPS. It is not known how hospitals affiliated with PPS-exempt cancer centers differ from other hospitals affiliated with National Cancer Institute cancer centers (NCI-CCs) or other US hospitals that provide cancer care.

OBJECTIVE

To examine differences between hospitals affiliated with PPS-exempt cancer centers, other hospitals affiliated with NCI-CCs, and other hospitals that provide cancer care on metrics that could be used in public reporting.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study compared hospital characteristics and cancer-related services using data from the American Hospital Association Annual Survey and US News Best Hospitals rankings. With a 100% sample of Medicare beneficiaries who underwent 1 of 9 cancer operations (brain tumor resection, colorectal resection, cystectomy, esophagectomy, gastrectomy, liver resection, lung resection, pancreatic resection, prostatectomy) from January 1, 2011, to May 31, 2015, we used hierarchical logistic regression methods to compare differences in 18 postoperative outcomes. Data analysis was conducted from February 2018 to August 2018.

MAIN OUTCOMES AND MEASURES

This study evaluated hospital characteristics, including cancer-specific services, patient comorbidity burden, and cancer surgery postoperative outcomes, from PPS-exempt cancer centers, NCI-affiliated cancer centers, and other US hospitals that provide cancer care.

RESULTS

Hospitals affiliated with PPS-exempt cancer centers (n = 15) and NCI-CCs (n = 54) were similar in hospital characteristics, basic cancer-related services, and patient comorbidity burden. Compared with NCI-CCs, PPS-exempt cancer centers had significantly higher US News reputation scores (mean [SD], 17.5 [24.0] vs 2.6 [4.8]; P < .001) but no differences in oncology patient volume, patient safety ratings, comorbidity burden, nurse staffing, US News total cancer scores, or US News survival scores. Hospitals affiliated with PPS-exempt cancer centers and NCI-CCs had similar adjusted postoperative outcomes for 15 of 18 measures, including mortality, readmission, and surgical site infections. Compared with hospitals affiliated with PPS-exempt cancer centers, patients treated at NCI-CCs were more likely to have postoperative sepsis (3.1% vs 1.7%; P = .002), acute renal failure (6.2% vs 3.9%; P = .01), and urinary tract infection (6.4% vs 4.0%; P = .002). Compared with the other hospitals that provide cancer care (n = 3578), PPS-exempt cancer center status was associated with improved outcomes for 7 of 18 measures, including mortality, sepsis, acute renal failure, pulmonary failure, and failure to rescue.

CONCLUSIONS AND RELEVANCE

Hospitals affiliated with PPS-exempt cancer centers and NCI-CCs had generally similar hospital characteristics, patient comorbidity burden, and cancer surgery outcomes. These findings raise questions about why some cancer centers are designated as PPS-exempt and why most hospitals are not required to publicly report cancer-specific quality metrics.

Trends in Volume-Outcome Relationship in Gastrectomies in Texas

BACKGROUND

We previously reported a significant volume-outcome relationship in mortality rates after gastrectomies for gastric cancer patients in Texas (1999-2001). We aimed to identify whether changes in the volume distribution of gastrectomies occurred, whether volume-outcome relationships persisted, and potential changes in the factors influencing volume-outcome relationships.

METHODS

We performed a population-based study using the Texas Inpatient Public Use Data File between 2010 and 2015. Hospitals were classified as high-volume centers (HVCs, > 15 cases per year), intermediate-volume centers (IVCs, 3-15 cases per year), and low-volume centers (LVCs, < 3 cases per year). We conducted multivariate analyses to evaluate factors associated with inpatient mortality and adverse events.

RESULTS

We identified 2733 gastric cancer patients who underwent gastrectomy at 193 hospitals. Fewer hospitals performed gastrectomy than previously (193 vs. 214). There were more HVCs (5 vs. 2) and LVCs (142 vs. 134), but fewer IVCs (46 vs. 78). The proportion of patients who underwent gastrectomy at HVCs and LVCs increased, while the proportion at IVCs decreased. HVCs maintained lower in-hospital mortality rates than IVCs or LVCs, although mortality rates decreased in both LVCs and IVCs. In adjusted multivariate analyses, treatment at HVCs remained a strong predictor for lower rates of mortality (odds ratio [OR] 0.39, p = 0.019) and adverse events (OR 0.56, p = 0.013).

CONCLUSION

Despite improvements, patient morbidity and mortality at LVCs and IVCs remain higher than at HVCs, demonstrating that volume-outcome relationships still exist for gastrectomy and that opportunities for improvement remain.

Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery

BACKGROUND

The relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality.

METHODS

A retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue).

RESULTS

A total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16-1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51-2.09), 30-day readmission (RR 1.21 95% CI 1.06-1.39), 90-day mortality (RR, 1.29, 95% CI 1.01-1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14-1.97).

CONCLUSION

Highest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality.

Association of Overlapping Surgery With Perioperative Outcomes

IMPORTANCE

Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes.

OBJECTIVE

To determine the association between overlapping surgery and mortality, complications, and length of surgery.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 66 430 operations in patients aged 18 to 90 years undergoing total knee or hip arthroplasty; spine surgery; coronary artery bypass graft (CABG) surgery; and craniotomy at 8 centers between January 1, 2010, and May 31, 2018. Patients were followed up until discharge.

EXPOSURES

Overlapping surgery (≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed).

MAIN OUTCOMES AND MEASURES

Primary outcomes were in-hospital mortality or complications (major: thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction; minor: urinary tract or surgical site infection) and surgery duration.

RESULTS

The final sample consisted of 66 430 operations (mean patient age, 59 [SD, 15] years; 31 915 women [48%]), of which 8224 (12%) were overlapping. After adjusting for confounders, overlapping surgery was not associated with a significant difference in in-hospital mortality (1.9% overlapping vs 1.6% nonoverlapping; difference, 0.3% [95% CI, -0.2% to 0.7%]; P = .21) or risk of complications (12.8% overlapping vs 11.8% nonoverlapping; difference, 0.9% [95% CI, -0.1% to 1.9%]; P = .08). Overlapping surgery was associated with increased surgery length (204 vs 173 minutes; difference, 30 minutes [95% CI, 24 to 37 minutes]; P < .001). Overlapping surgery was significantly associated with increased mortality and increased complications among patients having a high preoperative predicted risk for mortality and complications, compared with low-risk patients (mortality: 5.8% vs 4.7%; difference, 1.2% [95% CI, 0.1% to 2.2%]; P = .03; complications: 29.2% vs 27.0%; difference, 2.3% [95% CI, 0.3% to 4.3%]; P = .03).

CONCLUSIONS AND RELEVANCE

Among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length. Further research is needed to understand the association of overlapping surgery with these outcomes among specific patient subgroups.

Association of Adverse Effects of Medical Treatment With Mortality in the United States: A Secondary Analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study

IMPORTANCE

More than 20 years have passed since the first publication of estimates of the extent of medical harm occurring in hospitals in the United States. Since then, considerable resources have been allocated to improve patient safety, yet policymakers lack a clear gauge of the progress made.

OBJECTIVES

To quantify the cause-specific mortality associated with adverse effects of medical treatment (AEMT) in the United States from 1990 to 2016 by age group, sex, and state of residence and to describe trends in types of harm and associations with other diseases and injuries.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using 1990-2016 data on mortality due to AEMT from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study, which assessed death certificates of US decedents.

EXPOSURES

Death with International Classification of Diseases (ICD)-coded registration.

MAIN OUTCOMES AND MEASURES

Mortality associated with AEMT. Secondary analyses were performed on all ICD codes in the death certificate's causal chain to describe associations between AEMT and other diseases and injuries.

RESULTS

From 1990 to 2016, there were an estimated 123 603 deaths (95% uncertainty interval [UI], 100 856-163 814 deaths) with AEMT as the underlying cause. Despite an overall increase in the number of deaths due to AEMT over time, the national age-standardized mortality rate due to AEMT decreased by 21.4% (95% UI, 1.3%-32.2%) from 1.46 (95% UI, 1.09-1.76) deaths per 100 000 population in 1990 to 1.15 (95% UI, 1.00-1.60) deaths per 100 000 population in 2016. Men and women had similar rates of AEMT mortality, and those 70 years or older had mortality rates nearly 20-fold greater compared with those aged 15 to 49 years (mortality rate in 2016 for both sexes, 7.93 [95% UI, 7.23-11.45] per 100 000 population for those aged ≥70 years vs 0.38 [95% UI, 0.34-0.43] per 100 000 population for those aged 15-49 years). Per 100 000 population, California had the lowest age-standardized AEMT mortality rate at 0.84 deaths (95% UI, 0.57-1.47 deaths), whereas Mississippi had the highest mortality rate at 1.67 deaths (95% UI, 1.19-2.03 deaths). Surgical and perioperative events were the most common subtype of AEMT, accounting for 63.6% of all deaths for which an AEMT was identified as the underlying cause.

CONCLUSIONS AND RELEVANCE

This study's findings suggest a modest reduction in the mortality rate associated with AEMT in the United States from 1990 to 2016 while also observing increased mortality associated with advancing age and noted geographic variability. The annual GBD releases may allow for tracking of the burden of AEMT in the United States.

Perioperative complications and the cost of rescue or failure to rescue in hepato-pancreato-biliary surgery

BACKGROUND

It is unclear how either the successful or failed rescue of hepato-pancreato-biliary (HPB) patients from complications impacts costs.

METHODS

A retrospective cohort study of HPB surgical patients was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Patient demographics, characteristics, outcomes and risk-adjusted Medicare payments were compared.

RESULTS

11,596 patients were identified. Over half of the patients (n = 5,810, 50.1%) underwent liver surgery, while 42% (n = 4892) had pancreatic and 8% (n = 894) had biliary operations. The overall complication rate varied (liver: 19.6%; pancreas: 20.3%; biliary: 25.2%, p = 0.001). In general, both minor and serious complications resulted in higher Medicare payments. Failed rescue led to higher average Medicare payments during index hospitalization compared to successful rescue ($53,476 versus $44,636, p < 0.001). The reverse was true on readmission; successful rescue was associated with higher average Medicare payments ($25,746 versus $15,654, p < 0.001). Taken together (index plus readmission), total hospitalization payments were higher for failed compared to successful rescue ($66,604 versus $52,143, p < 0.001).

CONCLUSION

Following HPB surgery, there is a significant cost associated with both rescue and failure-to-rescue from perioperative complications. Total hospitalization cost was highest for patients who experienced failure-to-rescue.