Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes

Relationship between hospital surgical volume and the perioperative esophagectomy costs for esophageal cancer: a nationwide administrative claims database study

BACKGROUND

Numerous studies have described positive relationships between hospital volume (HV) and clinical outcomes in highly complex procedures, including esophagectomies. Although the centralization of surgery has been considered a possible solution for improving clinical outcomes, the HV impact on perioperative healthcare costs is unknown. This study aimed to determine the relationship between HV and perioperative healthcare costs for patients undergoing esophagectomy for esophageal cancer.

METHODS

This retrospective, nationwide cohort study used Japanese Administrative Claims Database data. Data on esophagectomies performed nationwide in 2015 were extracted. The outcome measure was perioperative healthcare costs per person from the perspective of the insurer. The healthcare costs in outpatient or inpatient settings of any hospital and clinic where patients received treatment were summed up from the month the surgery was performed to 3 months after. Linear regression analyses were conducted to assess the risk-adjusted effects of the HV category (1-4/5-9/10-14/15-) on perioperative costs.

RESULTS

A total of 5232 patients underwent an esophagectomy at 584 hospitals. The overall perioperative cost was 20.834 billion Japanese yen (JPY). The median perioperative costs per person for each HV category (1-4/5-9/10-14/15-) were 3.728 (709 patients), 3.740 (658 patients), 3.760 (512 patients), and 3.760 (3253 patients) million JPY, respectively (P = 0.676). Multivariate analyses revealed that each HV category had no significant impact on perioperative costs.

CONCLUSIONS

There were no significant differences in the perioperative costs between high- and low-volume centers. Esophageal cancer surgery centralization may be achievable without increasing healthcare costs.

Assessment of intermediate-term mortality following pancreatectomy for cancer

BACKGROUND

Pancreatic cancer remains highly lethal, and resection represents the only chance for cure. Although patients are counseled regarding short-term (0-3 months) mortality, little is known about mortality 3-6 months (intermediate-term) following surgery. We assessed predictors of intermediate-term mortality, evaluated hospital-level variation, and developed a nomogram to predict intermediate-term mortality risk.

METHODS

Patients undergoing pancreatic cancer resection were identified from the National Cancer Database (2010-2020). Multivariable logistic regression identified predictors of intermediate-term mortality and assessed differences between short-term and intermediate-term mortality. Multinomial regression grouped by intermediate-term mortality quartiles evaluated hospital-level variation. A neural network model was constructed to predict intermediate-term mortality risk. All statistical tests were 2-sided.

RESULTS

Of 45 297 patients, 3974 (8.9%) died within 6 months of surgery of which 2216 (5.1%) were intermediate-term. Intermediate-term mortality was associated with increasing T category, positive nodes, lack of systemic therapy, and positive margins (all P < .05) compared with survival beyond 6 months. Compared with short-term mortality, intermediate-term mortality was associated with treatment at high-volume hospitals, positive nodes, neoadjuvant systemic therapy, adjuvant radiotherapy, and positive margins (all P < .05). Median intermediate-term mortality rate per hospital was 4.5% (interquartile range [IQR] = 2.6-6.5). Highest quartile hospitals had decreased odds of treatment with neoadjuvant systemic therapy, neoadjuvant radiotherapy, and adjuvant radiotherapy (all P < .05). The neural network nomogram was highly accurate (accuracy = 0.9499; area under the receiver operating characteristics curve = 0.7531) in predicting individualized intermediate-term mortality risk.

CONCLUSION

Nearly 10% of patients undergoing pancreatectomy for cancer died within 6 months, of which one-half occurred in the intermediate term. These data have real-world implications to improve shared decision making when discussing curative-intent pancreatectomy.

Association of Hospital Volume With Quality Care Outcomes Following Minor and Major Hepatectomy for Primary Liver Cancer

INTRODUCTION

Regionalizing hepatic resections to high-volume hospitals (HVH) has improved outcomes, yet widened disparities in access. We sought to evaluate the association of hospital volume with quality care outcomes and overall survival (OS) between minor and major hepatectomy for primary liver cancer.

METHODS

The National Cancer Database identified patients with primary liver cancer who underwent minor/major hepatectomy (2009-2019). HVHs were defined by the top quartile in annual case volume (vs. the bottom three quartiles). Quality care outcomes (time to resection, margin status, length of stay, 30-day readmission, 30-day mortality, 90-day mortality) and OS were assessed using multivariable regression.

RESULTS

Overall, 6,988 patients underwent minor hepatectomy and 4880 major hepatectomy. No differences in quality care outcomes or OS based on hospital volume for minor hepatectomy were observed (all p > 0.05). Treatment at HVHs for major hepatectomy was associated with decreased odds of 30-day and 90-day mortality events (all p < 0.05). Median OS was 40.2 months [IQR 21.7-66.6] at HVHs versus 33.5 [IQR 17.0-58.7] at low-volume hospitals which remained independently predictive of improved OS on multivariable analysis (HR 0.86, 95% CI 0.79-0.93).

CONCLUSION

These results support regionalization to HVHs for major hepatectomy; however, minor hepatectomy can be safely performed at hospitals regardless of volume.

Utilization and survival outcomes of neoadjuvant chemotherapy for early-stage gastric cancer

BACKGROUND AND OBJECTIVES

Given increased utilization of neoadjuvant therapy (NAT) for gastric adenocarcinoma, practice patterns deviating from standard of care (upfront resection) remain unknown. We sought to identify factors associated with NAT use and survival outcomes among early-stage gastric cancers.

METHODS

The National Cancer Database identified patients with early-stage (T1N0M0) gastric cancer (2010-2020). Multivariable logistic regression assessed characteristics associated with NAT utilization compared to upfront surgery. After 1:1 propensity score matching, Kaplan-Meier methods and Cox regression assessed overall survival (OS).

RESULTS

Of 6452 patients with early-stage gastric cancer, 626 (9.7%) received NAT. Patients who received NAT were more likely treated at community hospitals, had moderate to poorly differentiated disease, and tumors located in the cardia (all p < 0.05). After propensity score matching, 1,248 patients remained. Median OS for NAT was 37.1 months (IQR 20.2-64.0) versus 45.6 months (IQR 22.5-72.8) for resection (p < 0.001). Treatment with NAT remained independently predictive of worse OS on Cox regression (hazard ratio 1.19; 95% confidence interval 1.05-1.34).

CONCLUSIONS

Although patients who received NAT had more aggressive prognostic features, NAT was associated with worse OS despite accounting for this selection bias. These results highlight the importance of adhering to guidelines, regardless of differing disease characteristics, which has significant implications on outcomes.

Assessing racial residential segregation as a risk factor for severe maternal morbidity

PURPOSE

To measure associations of area-level racial and economic residential segregation with severe maternal morbidity (SMM).

METHODS

We conducted a retrospective cohort study of births at two Philadelphia hospitals between 2018 and 2020 to analyze associations of segregation, quantified using the Index of Concentration at the Extremes (ICE), with SMM. We used stratified multivariable, multilevel, logistic regression models to determine whether associations of ICE with SMM varied by self-identified race or hospital catchment.

RESULTS

Of the 25,979 patients (44.1% Black, 35.8% White), 1381 (5.3%) had SMM (Black [6.1%], White [4.4%]). SMM was higher among patients residing outside (6.3%), than inside (5.0%) Philadelphia (P < .001). Overall, ICE was not associated with SMM. However, ICErace (higher proportion of White vs. Black households) was associated with lower odds of SMM among patients residing inside Philadelphia (aOR 0.87, 95% CI: 0.80-0.94) and higher odds outside Philadelphia (aOR 1.12, 95% CI: 0.95-1.31). Moran's I indicated spatial autocorrelation of SMM overall (P < .001); when stratified, autocorrelation was only evident outside Philadelphia.

CONCLUSIONS

Overall, ICE was not associated with SMM. However, higher ICErace was associated with lower odds of SMM among Philadelphia residents. Findings highlight the importance of hospital catchment area and referral patterns in spatial analyses of hospital datasets.

Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

IMPORTANCE

Although dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk.

OBJECTIVE

To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study from January 1, 2014, to December 31, 2018, evaluating inpatient surgery at acute care hospitals. A total of 119 757 Medicare beneficiaries aged 65 years or older who underwent colectomy, rectal resection, lung resection, or pancreatectomy were evaluated. Data were analyzed between November 1, 2020, and April 30, 2021.

EXPOSURES

Medicare and Medicaid DE status and hospital quality.

MAIN OUTCOMES AND MEASURES

Postoperative complications, readmission, and mortality by DE status and hospital quality.

RESULTS

Overall, 119 757 Medicare beneficiaries underwent colectomy, rectal resection, lung resection, or pancreatectomy. The mean (SD) age was 75.3 (6.7) years, 61 617 (51.5%) were women, 7677 (6.4%) were Black, 106 099 (88.6%) were White, and 5981 (5.0%) identified as another race or ethnicity; 11.3% had DE status. Dually eligible patients were more likely to be discharged to a facility (colectomy, 15.0% [95% CI, 14.7%-15.3%] vs 23.9% [95% CI, 22.9%-24.9%]; proctectomy, 18.7% [95% CI, 18.0%-19.3%] vs 26.9% [95% CI, 24.9%-28.9%]; lung resection, 11.0% [95% CI, 10.7%-11.3%] vs 17.9% [95% CI, 16.8%-18.9%]; pancreatectomy, 23.5% [95% CI, 22.5%-24.4%] vs 30.0% [95% CI, 26.5%-33.5%]). Differences in postacute care use persisted even after accounting for postoperative complications and contributed to variation in spending. Compared with the lowest-quality hospitals, DE patients had improved rates of discharge to a facility (22.7% vs 19.3%) and spending ($22 577 vs $20 100) but rates remained increased compared with Medicare patients even at the highest-quality hospitals.

CONCLUSIONS AND RELEVANCE

The findings of this study indicate that, even among the highest-quality hospitals, DE patients had poorer outcomes and higher spending. Dually eligible patients were more likely to be discharged to a facility and therefore incurred higher postacute care costs. Although treatment at high-quality hospitals is associated with reduced differences in outcomes, DE patients remain at high risk for adverse postoperative outcomes and increased readmissions and postacute care use.

Local Referral of High-risk Patients to High-quality Hospitals: Surgical Outcomes, Cost Savings, and Travel Burdens

OBJECTIVE

We sought to assess the potential changes in Medicare payments and clinical outcomes of referring high-risk surgical patients to local high-quality hospitals within small geographic areas.

SUMMARY BACKGROUND DATA

Previous studies have documented a benefit in referring high-risk patients to high-quality hospitals on a national basis, suggesting selective referral as a mechanism to improve the value of surgical care. Practically, referral of patients should be done within small geographic regions; however, the benefit of local selective referral has not been studied.

METHODS

We analyzed data on elderly Medicare beneficiaries undergoing any of 4 elective inpatient surgical procedures between 2012 and 2014. Hospitals were categorized into Metropolitan Statistical Areas by zip code and stratified into quintiles of quality based on rates of postoperative complications. Patient risk was calculated by modeling the predicted risk of a postoperative complication. Medicare payments for each surgical episode were calculated. Distances between patients' home zip code and high- and low-quality hospitals were calculated.

RESULTS

One quarter of high-risk patients underwent surgery at a low-quality hospital despite the availability of a high-quality hospital in their small geographic area. Shifting these patients to a local high-quality hospital would decrease spending 12% to 37% ($2,500 for total knee and hip replacement, $6,700 for colectomy, and $11,400 for lung resection). Approximately 45% of high-risk patients treated at low-quality hospitals could travel a shorter distance to reach a high-quality hospital than the low-quality hospital they received care at.

CONCLUSIONS

Complication rates and Medicare payments are significantly lower for high-risk patients treated at local high-quality hospitals. This suggests triaging high-risk patients to local high-quality hospitals within small geographic areas may serve as a template for improving the value of surgical care.

Local Referral of High-Risk Pancreatectomy Patients to Improve Surgical Outcomes and Minimize Travel Burden

BACKGROUND

Referring patients to high-quality hospitals for complex procedures may improve outcomes. This is most feasible within small geographic areas. However, access to specialized surgical procedures may be an implementation barrier. We sought to determine the availability of high-quality hospitals performing pancreatectomy and the potential benefit and travel burden of referral within small geographic areas.

METHODS

We identified elderly Medicare beneficiaries undergoing pancreatectomy between 2012 and 2014. Hospitals were stratified into quintiles of quality based on postoperative complication rates. Patient risk was assessed by modeling the predicted risk of developing a postoperative complication. The geographic unit of analysis was Metropolitan Statistical Area (MSA). Hospitals were categorized into MSA by zip code. Travel distance was calculated using patient and hospital zip code.

RESULTS

Among high-risk patients, 40.7% received care at the lowest-quality hospitals even though 80% had a high-quality hospital in the same MSA. Shifting these patients from low- to high-quality hospitals would decrease serious complications from 46.6 to 21.9% (P < 0.001) and mortality from 10.9 to 8.9% (P = 0.047). Three quarters of high-risk patients treated at low-quality hospitals could reach a high-quality hospital by extending their travel < 5 miles, and nearly 60% traveled farther to a low-quality hospital than was necessary to reach a high-quality hospital.

CONCLUSIONS

High-risk pancreatectomy patients often receive care at low-quality hospitals despite the availability of high-quality hospitals in the area or within an acceptable distance. Referral of high-risk patients to high-quality hospitals within small geographic areas may be an effective strategy to improve outcomes following pancreatic surgery.

Determinants of Rectal Cancer Patients' Decisions on Where to Receive Surgery: a Qualitative Analysis

BACKGROUND

Current literature suggests surgeons who perform large volumes of rectal cancer resections achieve superior outcomes, but only about half of rectal cancer resections are performed by high-volume surgeons in comprehensive hospitals. Little is known about the considerations of patients with rectal cancer when deciding where to receive surgery.

METHODS

A purposive sample of stage II/III rectal adenocarcinoma survivors diagnosed 2013-2015 were identified through the Iowa Cancer Registry and interviewed by telephone about factors influencing decisions on where to receive rectal cancer surgery.

RESULTS

Fifteen survivors with an average age of 63 were interviewed: 60% were male, 53% resided in non-metropolitan areas, and 60% received surgery at low-volume facilities. Most patients considered surgeon volume and experience to be important determinants of outcomes, but few assessed it. Recommendation from a trusted source, usually a physician, appeared to be a main determinant of where patients received surgery. Patients who chose low-volume centers noted comfort and familiarity as important decision factors.

CONCLUSION

Most rectal cancer patients in our sample relied on physician referrals to decide where to receive surgery. Interventions facilitating more informed decision-making by patients and referring providers may be warranted.

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations

The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.

Assessment of hospital-level adjusted breast cancer sentinel lymph node positivity rates

BACKGROUND/OBJECTIVES

Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival.

METHODS

Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004-2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles.

RESULTS

Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low- and high-tercile hospitals had statistically worse survival.

CONCLUSIONS

There is a wide variation in hospital SLNB positivity rates. Hospitals with lower- or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment.

Implications of Hospital Volume on Costs Following Esophagectomy in the United States

BACKGROUND

With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy.

METHODS

The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality.

RESULTS

In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001).

CONCLUSIONS

This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.

Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival

BACKGROUND

Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established.

OBJECTIVE

We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma.

METHODS

Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile.

RESULTS

Facility case volume was significantly associated with long-term patient survival (P < .0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities.

LIMITATIONS

Disease-specific survival was not available.

CONCLUSIONS

Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.

Locally advanced pancreas cancer: Staging and goals of therapy

BACKGROUND

Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer.

METHODS

An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed.

RESULTS

We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months.

CONCLUSION

Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.).

Adjusted Hospital Sentinel Lymph Node Positivity Rates in Melanoma: A Novel Potential Measure of Quality

OBJECTIVE

Our objectives were to examine whether hospital characteristics are associated with lower- and higher-than-expected sentinel lymph node biopsy (SLNB) positivity rates and whether hospitals with lower- or higher-than-expected SLNB positivity rates have worse patient outcomes.

BACKGROUND

Surgeon and pathologist SLNB technical errors may lead to incorrect melanoma staging. A hospital's SLNB positivity rate may reflect its SLNB proficiency for melanoma, but this has never been investigated.

METHODS

Stage IA-III melanoma patients undergoing SLNB were identified from the National Cancer Data Base (2004-2010). Hospital-level SLNB positivity rates were adjusted for patient- and tumor factors. Hospitals were divided into terciles of adjusted SLNB positivity rates. Hospital characteristics (using multinomial logistic regression) and survival (using Cox modeling) were examined across terciles.

RESULTS

Of 33,639 SLNB patients (from 646 hospitals), 2916 (8.7%) had at least 1 positive lymph node. Hospitals with lower- (low tercile) and higher-than-expected (high tercile) SLNB positivity rates were more likely to be low-volume hospitals (low tercile: relative risk ratio (RRR) = 2.57, P = 0.002; high tercile: RRR = 2.3, P = 0.004) compared to hospitals with expected rates (middle tercile). Stage I patients treated at lower-than-expected SLNB positivity rate hospitals had worse 5-year survival than those treated at expected SLNB positivity rate hospitals (90.0% vs 91.9%, P = 0.014; hazard ratio = 1.28, 95% CI: 1.05-1.57); survival differences were not observed by SLNB positivity rates for stage II/III.

CONCLUSIONS

Adjusted hospital SLNB positivity rates varied widely. Surgery at hospitals with lower-than-expected SLNB positivity rates was associated with decreased survival. Hospital SLNB positivity rates may be a novel measure to confidentially report to hospitals for internal quality assessment.

Hospital Characteristics Associated with Stage II/III Rectal Cancer Guideline Concordant Care: Analysis of Surveillance, Epidemiology and End Results-Medicare Data

BACKGROUND

Evidence suggests that high-volume facilities achieve better rectal cancer outcomes.

METHODS

Logistic regression was used to evaluate association of facility type with treatment after adjusting for patient demographics, stage, and comorbidities. SEER-Medicare beneficiaries who were diagnosed with stage II/III rectal adenocarcinoma at age ≥66 years from 2005 to 2009 and had Parts A/B Medicare coverage for ≥1 year prediagnosis and postdiagnosis plus a claim for cancer-directed surgery were included. Institutions were classified according to National Cancer Institute (NCI) designation, presence of residency program, or medical school affiliation.

RESULTS

Two thousand three hundred subjects (average age = 75) met the criteria. Greater proportions of those treated at NCI-designated facilities received transrectal ultrasound (TRUS) or magnetic resonance imaging (MRI)-pelvis (62.1 vs. 29.9 %), neoadjuvant chemotherapy (63.9 vs. 41.8 %), and neoadjuvant radiation (70.8 vs. 46.3 %), all p < 0.0001. On multivariate analysis, odds ratios (95 % confidence intervals) for receiving TRUS or MRI, neoadjuvant chemotherapy, or neoadjuvant radiation among beneficiaries treated at NCI-designated facilities were 3.51 (2.60-4.73), 2.32 (1.71-3.16), and 2.66 (1.93-3.67), respectively. Results by residency and medical school affiliation were similar in direction to NCI designation.

CONCLUSIONS

Those treated at hospitals with an NCI designation, residency program, or medical school affiliation received more guideline-concordant care. Initiatives involving provider education and virtual tumor boards may improve care.

Starting a High-Quality Pancreatic Surgery Program at a Community Hospital

BACKGROUND

Most literature suggests that pancreatic resections should be done by high-volume surgeons at high-volume hospitals to optimize patient outcomes. However, patient preference and insurance requirements may restrict hospital location. After careful planning, a high-volume pancreatic surgeon started performing pancreatectomies at a community hospital.

METHODS

Sixty pancreatectomies were performed at an academic medical center and 28 at a 144-bed community, non-teaching hospital. Sixty-day outcomes were recorded.

RESULTS

There were no statistically significant differences between the academic medical center and community hospital with regard to the median age of the patients (66 vs. 61 years), the gender distribution (57 vs. 64 % female), or the median BMI (28 vs. 26 kg/m(2)). There was a significant difference in the American Society of Anesthesiologists class distribution between the academic medical center and community hospital (1; 0 vs. 4 %, 2; 7 vs. 21 %, 3; 88 vs. 75 %, 4; 5 vs. 0 %, p = 0.006). The median length of stay (LOS) for 17 pancreaticoduodenectomy/total pancreatectomy patients at the community hospital was significantly less than for 39 patients at the academic medical center (5 vs. 7 days, p = 0.006). Eleven distal pancreatectomy/splenectomy patients at the community hospital tended to have a shorter median LOS than 21 patients at the academic medical center (4 vs. 5 days, p = 0.25). Accordion ≥ 3 complications (7 vs. 27 %) and readmissions (11 vs. 22 %) tended to be lower at the community hospital than the academic medical center. Greater than 80 % of patients with adenocarcinoma at both hospital settings who were recommended to receive adjuvant therapy started their treatment within 60 days of surgery.

CONCLUSIONS

With appropriate planning and careful patient selection, high-quality pancreatic surgery can be performed at a community hospital by a high-volume pancreatic surgeon.

Outcomes and Costs for Major Lung Resection in the United States: Which Patients Benefit Most From High-Volume Referral?

BACKGROUND

Accountable care organizations are designed to improve value by decreasing costs and maintaining quality. Strategies to maximize value are needed for high-risk surgery. We wanted to understand whether certain patient groups were differentially associated with better outcomes at high-volume hospitals in terms of quality and cost.

METHODS

In all, 37,746 patients underwent elective major lung resection in 1,273 hospitals in the Nationwide Inpatient Sample from 2007 to 2011. Patients were stratified by hospital volume quartile and substratified by preoperative mortality risk, age, and chronic obstructive pulmonary disease status. Mortality was evaluated using clustered multivariable hierarchical logistic regression controlling for patient comorbidity, demographics, and procedure. Adjusted cost was evaluated using generalized linear models fit to a gamma distribution.

RESULTS

Patients were grouped into volume quartiles based on cases per year (less than 21, 21 to 40, 40 to 78, and more than 78). Patient characteristics and procedure mix differed across quartiles. Overall, mortality decreased across volume quartiles (lowest 1.9% versus highest 1.1%, p < 0.0001). Patients aged more than 80 years were associated with greater absolute and relative mortality rates than patients less than 60 years old in highest volume versus lowest volume hospitals (age more than 80 years, 4.2% versus 1.3%, p < 0.0001, odds ratio 3.31, 95% confidence interval: 1.89 to 5.80; age less than 60 years, 1.0% versus 0.8%, p = 0.19, odds ratio 1.38, 95% confidence interval: 0.74 to 2.56). Patients with high preoperative risk (more than 75th percentile) were also associated with lower absolute mortality in high-volume hospitals. Adjusted costs were not significantly different across quartiles or patient strata.

CONCLUSIONS

Older patients show a significantly stronger volume-outcome relationship than patients less than 60 years of age. Costs were equivalent across volume quartile and patient strata. Selective patient referral may be a strategy to improve outcomes for elderly patients undergoing lung resection.

Variation in performance of candidate surgical quality measures for muscle-invasive bladder cancer by hospital type

OBJECTIVE

To test the association between hospital type and performance of candidate quality measures for treatment of muscle-invasive bladder cancer (MIBC) using a large national tumour registry. Proposed quality measures include receipt of neoadjuvant chemotherapy, timely treatment, adequate lymph node dissection, and continent urinary diversion.

PATIENTS AND METHODS

Using the National Cancer Database, patients with stage ≥II urothelial carcinoma treated with radical cystectomy (RC) from 2003 to 2010 were identified. Hospitals were grouped by type and annual RC volume: community, comprehensive low volume (CLV), comprehensive high volume (CHV), academic low volume (ALV), and academic high volume (AHV) groups. Logistic regression models were used to test the association between hospital group and performance of quality measures, adjusting for year, demographic, and clinical/pathological characteristics; generalised estimating equations were fitted to the models to adjust for clustering at the hospital level.

RESULTS

In all, 23 279 patients underwent RC at community (12.4%), comprehensive (CLV 38%, CHV 5%), and academic (ALV 17%, AHV 28%) hospitals. While only 0.8% (175) of patients met all four quality criteria, 61% of patients treated at AHV hospitals met two or more quality metric indicators compared with ALV (45%), CHV (44%), CLV (38%), and community (37%) hospitals (P < 0.001). After adjustment, patients were more likely to receive two or more quality measures when treated at AHV (odds ratio [OR] 2.4, confidence interval [CI] 2.0-2.9), ALV (OR 1.3, CI 1.1-1.6), and CHV (OR 1.3, CI 1.03-1.7) hospitals compared with community hospitals.

CONCLUSIONS

Patients undergoing RC at AHV hospitals were more likely to meet quality criteria. However, performance remains low across hospital types, highlighting the opportunity to improve quality of care for MIBC.

Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer

BACKGROUND

Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States.

METHODS

From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided.

RESULTS

Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P < .001) and from 6.6% to 20.9% for T1b cancers (P < .001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2 cm (vs. <2 cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2 cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47).

CONCLUSIONS

Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.

Outcomes of pancreaticoduodenectomy for pancreatic malignancy in octogenarians: an American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Most series analyzing outcomes of pancreaticoduodenectomy in octogenarians are limited by a small sample size. The investigators used the American College of Surgeons National Surgical Quality Improvement Program database for an analysis of the impact of advanced age on outcomes after pancreatic cancer surgery.

METHODS

The National Surgical Quality Improvement Program database from 2005 to 2010 was accessed to study the outcomes of 475 pancreaticoduodenectomies performed in patients ≥80 years of age compared with 4,102 patients <80 years of age using chi-square and Student's t tests. A multivariate logistic regression was used to analyze factors associated with 30-day mortality and the occurrence of major complications.

RESULTS

Octogenarians had significantly more preoperative comorbidities compared with patients <80 years of age. On multivariate analysis, age ≥80 years was associated with an increased likelihood of experiencing 30-day mortality and major complications compared with patients <80 years of age. On subgroup analysis, septuagenarians had a similar odds ratio of experiencing mortality or complications compared with octogenarians, whereas patients <70 years of age were at lower risk.

CONCLUSIONS

Although octogenarians have an increased risk for mortality and major complications compared with patients <80 years of age, on subgroup analysis, they do not differ from septuagenarians.

Trends in hospital volume and patterns of referral for women with gynecologic cancers

OBJECTIVE

To estimate trends in hospital volume and referral patterns for women with uterine and ovarian cancer.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged 65 years or older with ovarian and uterine cancer who underwent surgery from 2000 to 2007. "Volume creep," when a greater number of patients undergo surgery at the same hospitals, and "market concentration," when a similar overall number of patients undergo a procedure but at a smaller number of hospitals, were analyzed.

RESULTS

Among 4,522 patients with ovarian cancer, mean hospital volume increased from 3.1 cases during 2000-2001 to 3.4 cases during 2006-2007 (P=.62) suggesting minimal volume creep. Similarly, there was little evidence of market concentration. In 2000-2001, 37.8% of women were treated at the top decile by volume hospitals compared with 41.4% in 2006-2007 (P=.14). In 2006-2007, 201 (63.2%) of the hospitals had an ovarian cancer surgery volume of two or fewer cases. Among 9,908 women with uterine cancer, the mean hospital volume increased slightly from 4.5 in 2000-2001 to 5.4 in 2006-2007 (P=.10). The percentage of patients treated at the top decile by volume of hospitals increased from 40.4% in 2000-2001 to 44.7% in 2006-2007 (P<.001). In 2006-2007, 243 (49.3%) of the hospitals had a uterine cancer surgery volume of two or fewer cases.

CONCLUSION

There have been only modest changes in the referral patterns of women with ovarian and uterine cancer. A large number of hospitals have a very low procedural volume.

Clinical review: Can we predict which patients are at risk of complications following surgery?

There are a vast number of operations carried out every year, with a small proportion of patients being at highest risk of mortality and morbidity. There has been considerable work to try and identify these high-risk patients. In this paper, we look in detail at the commonly used perioperative risk prediction models. Finally, we will be looking at the evolution and evidence for functional assessment and the National Surgical Quality Improvement Program (in the USA), both topical and exciting areas of perioperative prediction.

Efficiency of colorectal cancer care among veterans: analysis of treatment wait times at Veterans Affairs Medical Centers

PURPOSE

Timeliness of cancer treatment is an important aspect of health care quality. Veterans Affairs Medical Centers (VAMCs) are expected to treat a growing number of patients with cancer. Our objectives were to examine treatment times from diagnosis to first-course therapy for patients with colon and rectal cancers and assess factors associated with prolonged wait times.

METHODS

From the VA Central Cancer Registry, patients who underwent colon or rectal resection for cancer from 1998 to 2008 were identified. Time from diagnosis to definitive cancer-directed therapy was measured, and multivariable regression methods were used to determine predictors of prolonged wait times for colon (≥ 45 days) and rectal (≥ 60 days) cancers.

RESULTS

From 124 VAMCs, 14,097 patients underwent colectomy, and 3,390 underwent rectal resection for cancer. For colon cancer, the median time to treatment increased by 68% over time (P < .001). From 2007 to 2008, the median time to colectomy was 32 days. Predictors of prolonged wait times included age ≥ 55 years (v < 55 years), time period (2007 to 2008 v 1998 to 2000), black race (v white), marriage status (married v unmarried), high-volume center status (v low volume), and treatment at a different hospital (v same hospital as initial diagnosis; all P < .05). For rectal cancer, the overall median time to first-course treatment increased by 74% (P < .001). From 2007 to 2008, the median time to proctectomy was 47 days. Similar predictors of prolonged wait times were identified for rectal cancer.

CONCLUSION

Time to first treatment has increased for patients with colon and rectal cancers at VAMCs. Patient, tumor, and hospital factors are associated with prolonged time to treatment.

Is Illinois heeding the call to regionalize pancreatic surgery?

BACKGROUND AND OBJECTIVES

Recommendations to refer pancreatic procedures to high-volume centers have been in place for a decade. We sought to determine whether regionalization of pancreatic procedures to high-volume centers is occurring in Illinois.

METHODS

We compared pancreatic procedures performed in Illinois hospitals from 2000 to 2004 [time period (TP) 1] versus 2005-2009 (TP2) for changes in inpatient mortality and hospital volume. Hospitals were categorized into low- (LVH), intermediate- (IVH), or high-volume (HVH).

RESULTS

From TP1 to TP2, there was a 23% increase in absolute case volume (2,232-2,737), despite fewer hospitals performing pancreatic procedures (114-95). In hospital mortality decreased (5.5-3.3%, P < 0.01) and was lowest at HVHs. LVHs and IVHs were associated with a 4.7 and 3.0 higher odds of mortality, respectively (both P < 0.001). Overall, HVHs performed 659 (+73%) more procedures, whereas cumulative procedure volume dropped by 154 cases at LVHs (+1%) and IVHs (-18%).

CONCLUSIONS

We observed limited evidence of regionalization of pancreatic procedures in Illinois. The increase in HVH case volume cannot be solely attributed to regionalization, given the corresponding modest decrease seen at non-HVHs. There is opportunity for Illinois hospitals to implement strategies such as selective referral to improve mortality after pancreatic resection.

Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit

AIMS

The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database.

METHODS

6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately.

RESULTS

For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors.

CONCLUSIONS

For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

Preoperative optimization: rationale and process: is it economic sense?

PURPOSE OF REVIEW

The development of preoperative clinics and the increasing importance of the anaesthetist in the management of surgical risk have expanded the concept of preoperative optimization. This review will focus on the rationale and process for cost-effective preoperative optimization.

RECENT FINDINGS

Postoperative morbidity, rather than mortality, is the most important surgical outcome in economic terms. Since preoperative comorbidity, in association with surgical complexity, is more predictive of hospital costs than the subsequent treatment of postoperative complications per se, preoperative optimization represents an appropriate economic target. Process management, including guidelines to reduce unnecessary investigations and specialist referrals and enhancing perioperative recovery, makes economical sense in the majority of patients who undergo noncardiac surgery with few complications. Preoperative optimization of a minority of high-risk surgical patients is also important given limited critical care resource. However, the evidence for specific optimization strategies in this latter group continues to evolve and requires further clarification in well designed trials.

SUMMARY

The requirement for appropriate methods of risk stratification of surgical patients targeted at the reduction of postoperative morbidity, underpins the development of cost-effective preoperative optimization. Specific process-based and clinical measures may then be applied to the development of individualized perioperative care packages.

Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011

BACKGROUND

The aim of this study is to provide a contemporary quantitative analysis of the existing literature examining the relationship between surgical caseload and outcome following esophageal resection.

METHODS

Medline, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following esophagectomy from high- and low-volume hospitals since 2000. Primary outcomes were in-hospital and 30-day mortality. Secondary outcomes were length of hospital stay and post-operative complications.

RESULTS

Nine appropriate publications comprising 27,843 esophagectomy operations were included, 12,130 and 15,713 operations were performed in low- and high-volume surgical units, respectively. Esophagectomy at low-volume hospitals was associated with a significant increase in incidence of in-hospital (8.48% vs. 2.82%; pooled odds ratio (POR) = 0.29; P < 0.0001) and 30-day mortality (2.09% vs. 0.73%; POR = 0.31; P < 0.0001). There was insufficient data for conclusive statistical analysis of length of hospital stay or post-operative complications.

CONCLUSIONS

This meta-analysis does suggest a benefit in the centralization of esophageal cancer surgery to high-volume institutions with respect to mortality. The outcomes of this study are of interest to patients, healthcare providers and payers, particularly regarding service reconfiguration and more specifically centralization of services. Future studies that look at long-term survival will help improve understanding of any late consequences such as survival and quality of life following esophageal surgery at low- and high-volume hospitals.

Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis

OBJECTIVE

To study the differences in short and long-term outcomes of transthoracic and transhiatal esophagectomy for cancer.

BACKGROUND

Studies have compared transthoracic with transhiatal esophagectomy with varying results. Previous systematic reviews (1999, 2001) do not include the latest randomized controlled trials.

METHODS

Systematic review of English-language studies comparing transthoracic with transhiatal esophagectomy up to January 31, 2010. Meta-analysis was used to summate the study outcomes. Methodological and surgical quality of included studies was assessed.

RESULTS

Fifty-two studies, comprising 5905 patients (3389 transthoracic and 2516 transhiatal) were included in the analysis. No study met all minimum surgical quality standards. Transthoracic operations took longer and were associated with a significantly longer length of stay. There was no difference in blood loss. The transthoracic group had significantly more respiratory complications, wound infections, and early postoperative mortality, whereas anastomotic leak, anastomotic stricture, and recurrent laryngeal nerve palsy rate was significantly higher in the transhiatal group. Lymph node retrieval was reported in 4 studies and was significantly greater in the transthoracic group by on average 8 lymph nodes. Analysis of 5-year survival showed no significant difference between the groups and was subject to significant heterogeneity.

CONCLUSIONS

This meta-analysis of studies comparing transthoracic with transhiatal esophagectomy for cancer demonstrates no difference in 5-year survival, however lymphadenectomy and reported surgical quality was suboptimal in both groups and the transthoracic group had significantly more advanced cancer. The finding of equivalent survival should therefore be viewed with caution.

Treatment of pancreatic and periampullary cancers at a community hospital: successful application of tertiary care treatment standards

Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006–2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.

Rectal cancer surgery: volume-outcome analysis

PURPOSE

There is strong evidence supporting the importance of the volume-outcome relationship with respect to lung and pancreatic cancers. This relationship for rectal cancer surgery however remains unclear. We review the currently available literature to assess the evidence base for volume outcome in relation to rectal cancer surgery.

METHODS

We analysed the Medline "PubMed" online database using the keyword search parameters of "rectal cancer", "hospital volume or caseload", "surgeon volume or caseload", "outcomes", "mortality", "approach", "local recurrence" and "morbidity" for the time period 1997-2009. Five hundred twenty-six generic articles were identified. Articles that were not specific for, or separately identified, rectal cancer surgery in their individual analysis were excluded. Eighteen articles remained for review. We assessed short-term morbidity and long-term outcomes such as sphincter preservation, mortality and local recurrence rates.

RESULTS

Considerable variance was noted in the definition of high volume and low volume. Postoperative length of stay was lower and sphincter-preserving surgery was more commonly performed in high-volume hospitals and by high-volume surgeons. Surgeon specialisation was an important factor influencing sphincter preservation, survival and local recurrence rates. Volume was found to have no negative relationship with mortality and a positive one with local recurrence. Interestingly, there was no association found between hospital or surgeon caseload and postoperative morbidity.

CONCLUSION

There is a paucity of evidence in the literature regarding the volume-outcome relationship with regard to rectal cancer surgery. High-volume institutions yielded shorter lengths of stay. However, the key finding was that high-volume surgeons that specialised in colorectal surgery yielded objectively improved outcomes for patients with rectal cancer.

A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts

OBJECTIVES

Authors hypothesized that building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with "real-time" mitigation of risk. We developed a comanagement model for hospitalized surgical cohort, and determined whether this iterative process redesign for surgery will be adaptable to disparate hospital systems and will be beneficial for combined medical/surgical adult inpatients.

CONTEXT

Concerns about preventable harm in hospitalized patients have generated a plethora of both, process-driven and outcome-based strategies in US Healthcare. Although comparison between hospitals is a common mechanism to drive quality, other innovative approaches are needed for real-time risk mitigation to improve outcomes.

METHODS

Prospective implementation of Surgical Continuum of Care (SCoC) model in hospitals initially for surgery patients; subsequently Continuum of Care (CoC) for medical/surgical population. Redesign of hospital care delivery model: patient cohorting, floor-based team building, and intensivist/hospitalist staffing of progressive care unit (PCU). Work flow redesign for clinical effectiveness: multidisciplinary team rounds, acuity stratified care rounding based on dynamic risk assessment into a novel HAWK (high risk)/DOVE (low risk) patient grouping, intensivist/hospitalist comanagement of surgical patients, and targeted response.

STUDY

Pre- and postintervention with concurrent cohort control design.

SETTING

Academic medical centers for SCoC and integrated health system hospital for CoC.

PATIENT GROUPS

SCoC Pilot Study-Campus A: Preintervention control group 1998-2000, Intervention Group 2001-2004; Campus B: Comparator Control Group 1998-2004. SCoC Validation Study-Campus C: Preintervention Group 2001-2005; Intervention Group 2006-2008. CoC Study-Campus D: Hospital-wide Group 2009. METRICS: Mortality, length of stay (LOS): overall, surgical intensive care unit and PCU, readmission rates, and cost. Case mix index for risk adjustment.

RESULTS

Total >100,000 admissions. There was a significant reduction in overall surgical mortality in both, pilot (P < 0.002) and validation (P < 0.02) SCoC studies and overall hospital mortality in the medical/surgical CoC study (risk-adjusted mortality index progressively declined in CoC study from 1.16 pre-CoC to 0.77 six months post-CoC implementation; significant at 75% confidence level). Case mix index was unchanged during study period in each campus. Nested study in validation cohort of hospital-wide versus surgery alone (observed/expected mortality index) demonstrated significant benefit to SCoC in intervention group. The mortality benefit was primarily derived from risk-stratified rounding and actively managing risk prone population in the PCU. Surgical intensive care unit, PCU, and total hospital patient-days significantly decreased in SCoC pilot study (P < 0.05), reflecting enhanced throughput. LOS reduction benefit persisted in SCoC validation and CoC studies. In addition to decreased LOS, cost savings were in PCU (range, $851,511-2,007,388) and top diagnosis-related groups, for example, $452 K/yr for diagnosis-related group 148.

CONCLUSIONS

SCoC is patient-centered, outcomes-driven, value-based approach for hospital-wide surgical patient safety. The principles of this value paradigm are adaptable to other hospitals as demonstrated in our longitudinal study in 3 hospital systems, and the initial experience of CoC suggests that this model will have benefit beyond surgical hospital cohort.