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Heath M, Bernstein SJ, Paje D, McLaughlin E, Horowitz JK, McKenzie A, Leyden T, Flanders SA, Chopra V. Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00102-8. [PMID: 38762387 DOI: 10.1016/j.jcjq.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. METHODS The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates. RESULTS Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003). CONCLUSION A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.
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Kalata S, Reddy RM, Norton EC, Clark MJ, He C, Leyden T, Adams KN, Popoff AM, Lall SC, Lagisetty KH. Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database. J Thorac Cardiovasc Surg 2024; 167:1469-1478.e3. [PMID: 37625618 DOI: 10.1016/j.jtcvs.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives. METHODS Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement. RESULTS We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change. CONCLUSIONS Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | | | - Edward C Norton
- Departments of Health Management and Policy and Economics, University of Michigan, Ann Arbor, Mich
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | | | - Kumari N Adams
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Mich
| | - Andrew M Popoff
- Department of Thoracic Surgery, Henry Ford Hospital, Detroit, Mich
| | - Shelly C Lall
- Department of Thoracic Surgery, Munson Medical Center, Traverse City, Mich
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Codner JA, Mlaver E, Solomon G, Saeed M, Di M, Shaffer VO, Dente CJ, Sweeney JF, Patzer RE, Sharma J. Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative. Surg Infect (Larchmt) 2024; 25:63-70. [PMID: 38157325 DOI: 10.1089/sur.2023.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Eli Mlaver
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Gina Solomon
- Georgia Trauma Commission, Atlanta, Georgia, USA
| | - Muhammad Saeed
- Department of Surgery, Augusta University, Augusta, Georgia, USA
| | - Mengyu Di
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | - John F Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Rachel E Patzer
- Department of Surgery, Emory University, Atlanta, Georgia, USA
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McGowan JG, Martin GP, Krapohl GL, Campbell DA, Englesbe MJ, Dimick JB, Dixon-Woods M. What are the features of high-performing quality improvement collaboratives? A qualitative case study of a state-wide collaboratives programme. BMJ Open 2023; 13:e076648. [PMID: 38097243 PMCID: PMC10729078 DOI: 10.1136/bmjopen-2023-076648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Despite their widespread use, the evidence base for the effectiveness of quality improvement collaboratives remains mixed. Lack of clarity about 'what good looks like' in collaboratives remains a persistent problem. We aimed to identify the distinctive features of a state-wide collaboratives programme that has demonstrated sustained improvements in quality of care in a range of clinical specialties over a long period. DESIGN Qualitative case study involving interviews with purposively sampled participants, observations and analysis of documents. SETTING The Michigan Collaborative Quality Initiatives programme. PARTICIPANTS 38 participants, including clinicians and managers from 10 collaboratives, and staff from the University of Michigan and Blue Cross Blue Shield of Michigan. RESULTS We identified five features that characterised success in the collaboratives programme: learning from positive deviance; high-quality coordination; high-quality measurement and comparative performance feedback; careful use of motivational levers; and mobilising professional leadership and building community. Rigorous measurement, securing professional leadership and engagement, cultivating a collaborative culture, creating accountability for quality, and relieving participating sites of unnecessary burdens associated with programme participation were all important to high performance. CONCLUSIONS Our findings offer valuable learning for optimising collaboration-based approaches to improvement in healthcare, with implications for the design, structure and resourcing of quality improvement collaboratives. These findings are likely to be useful to clinicians, managers, policy-makers and health system leaders engaged in multiorganisational approaches to improving quality and safety.
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Affiliation(s)
- James G McGowan
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Graham P Martin
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Greta L Krapohl
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Dixon-Woods
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Janda AM, Vaughn MT, Colquhoun D, Mentz G, Buehler MS RN CPPS K, Nathan H, Regenbogen SE, Syrjamaki J, Kheterpal S, Shah N. Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study. Anesth Analg 2023; 137:1093-1103. [PMID: 37678254 PMCID: PMC10592579 DOI: 10.1213/ane.0000000000006565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. METHODS In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. RESULTS We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. CONCLUSIONS Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.
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Affiliation(s)
- Allison M. Janda
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Michelle T. Vaughn
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Douglas Colquhoun
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kathryn Buehler MS RN CPPS
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hari Nathan
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | | | - John Syrjamaki
- Michigan Value Collaborative (MVC), Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Nirav Shah
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Somerset AE, Wood MH, Bonham AJ, Carlin AM, Finks J, Ghaferi AA, Varban OA. Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality? Surg Endosc 2023; 37:8570-8576. [PMID: 37872428 DOI: 10.1007/s00464-023-10411-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 07/30/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes. METHODS Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles. RESULTS Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001). CONCLUSIONS Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.
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Affiliation(s)
- Amy E Somerset
- Department of Surgery, Detroit Medical Center, Wayne State University, 3990 John R, Detroit, MI, 48201, USA.
| | - Michael H Wood
- Department of Surgery, Detroit Medical Center, Wayne State University, 3990 John R, Detroit, MI, 48201, USA
| | - Aaron J Bonham
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Jonathan Finks
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Oliver A Varban
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
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Lambrecht J, Abir M, Seiler K, Kamdar N, Peterson T, Lin P, Nham W, Greenwood-Ericksen M. Conceptualizing lifer versus destination patients for optimized care delivery. BMC Health Serv Res 2023; 23:1190. [PMID: 37915060 PMCID: PMC10619315 DOI: 10.1186/s12913-023-10214-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/26/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Patients presenting to academic medical centers (AMC) typically receive primary care, specialty care, or both. Resources needed for each type of care vary, requiring different levels of care coordination. We propose a novel method to determine whether a patient primarily receives primary or specialty care to allow for optimization of care coordination. OBJECTIVES We aimed to define the concepts of a Lifer Patient and Destination Patient and analyze the current state of care utilization in those groups to inform opportunities for improving care coordination. METHODS Using AMC data for a 36-month study period (FY17-19), we evaluated the number of unique patients by residence zip code. Patients with at least one primary care visit and patients without a primary care visit were classified as Lifer and Destination patients, respectively. Cohen's effect sizes were used to evaluate differences in mean utilization of different care delivery settings. RESULTS The AMC saw 35,909 Lifer patients and 744,037 Destination patients during the study period. Most patients were white, non-Hispanic females; however, the average age of a Lifer was seventy-two years whereas that of a Destination patient was thirty-eight. On average, a Lifer had three times more ambulatory care visits than a Destination patient. The proportion of Inpatient encounters is similar between the groups. Mean Inpatient length of stay (LOS) is similar between the groups, but Destination patients have more variance in LOS. The rate of admission from the emergency department (ED) for Destination patients is nearly double Lifers'. CONCLUSION There were differences in ED, ambulatory care, and inpatient utilization between the Lifer and Destination patients. Furthermore, there were incongruities between rate of hospital admissions and LOS between two groups. The Lifer and Destination patient definitions allow for identification of opportunities to tailor care coordination to these unique groups and to allocate resources more efficiently.
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Affiliation(s)
- Jacob Lambrecht
- Department of Emergency Medicine, University of Michigan, TC B1-220 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
- Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Mahshid Abir
- Department of Emergency Medicine, University of Michigan, TC B1-220 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
- RAND Corporation, Santa Monica, CA, USA.
| | - Kristian Seiler
- Data and Methods Hub, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Neil Kamdar
- Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Data and Methods Hub, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Tim Peterson
- Department of Emergency Medicine, University of Michigan, TC B1-220 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
- Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Paul Lin
- Data and Methods Hub, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Wilson Nham
- Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Emergency Medicine Research, University of Michigan, Ann Arbor, MI, USA
| | - Margaret Greenwood-Ericksen
- Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
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Topcu AC, Magouliotis DE, Milojevic M, Bond CJ, Clark MJ, Theurer PF, Pagani FD, Pruitt AL, Prager RL. Lessons learned from the EACTS-MSTCVS quality fellowship: a call to action for continuous improvement of cardiothoracic surgery outcomes in Europe. Eur J Cardiothorac Surg 2023; 64:ezad293. [PMID: 37653577 DOI: 10.1093/ejcts/ezad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023] Open
Abstract
The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings annually. It actively engages cardiac and general thoracic surgeons, data managers and researchers from all 32 non-federally funded cardiothoracic surgery sites across Michigan. Broadening its influence on joint learning and clinical outcomes, the MSTCVS-QC formed a strategic partnership with Blue Cross Blue Shield of Michigan, the state's largest private insurer, to further promote its initiatives. The MSTCVS-QC, operating from a dedicated QC centre employs an STS-associated database with additional aspects for data collection and analysis. The QC centre also organizes audits, facilitates collaborative meetings, disseminates surgical outcomes and champions the development and implementation of quality improvement initiatives related to cardiothoracic surgery in Michigan. Recognizing the MSTCVS-QC's successful efforts in advancing quality improvement, the European Association for Cardiothoracic Surgery (EACTS) introduced a fellowship program in 2018, facilitated through the EACTS Francis Fontan Fund (FFF). This program allows early-career academic physicians to spend 4-6 months with the MSTCVS-QC team in Ann Arbor. This article chronicles the evolution and functionality of the MSTCVS-QC, enriched by the experiences of the inaugural 4 EACTS/FFF fellows. Our objective is to emphasize the critical importance of fostering a culture of quality improvement and patient safety in the field of cardiothoracic surgery with open discussion of audited, high-quality data points. This principle, while implemented locally, has implications and value extending far beyond Europe, resonating globally.
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Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | | | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Chris J Bond
- Department of Cardiac Surgery, Queen Elizabeth University Hospital, Birmingham, UK
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Patricia F Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Francis D Pagani
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Andrew L Pruitt
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiothoracic Surgery, Saint Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
| | - Richard L Prager
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
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Howard R, Hendren S, Patel M, Gunaseelan V, Wixson M, Waljee J, Englesbe M, Bicket MC. Racial and Ethnic Differences in Elective Versus Emergency Surgery for Colorectal Cancer. Ann Surg 2023; 278:e51-e57. [PMID: 35950753 PMCID: PMC11062257 DOI: 10.1097/sla.0000000000005667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To evaluate differences in presentation and outcomes of surgery for colorectal cancer. BACKGROUND Although racial and socioeconomic disparities in colorectal cancer outcomes are well documented, disparities in access affecting disease presentation are less clear. METHODS We conducted a statewide retrospective study of patients who underwent resection for colorectal cancer between January 1, 2015, and April 30, 2021. The primary outcome was undergoing emergency surgery. Secondary outcomes included preoperative evaluation and postoperative outcomes. Covariates of interest included race/ethnicity, social deprivation index, and insurance type. RESULTS A total of 4869 patients underwent surgery for colorectal cancer, of whom 1122 (23.0%) underwent emergency surgery. Overall, 28.1% of Black non-Hispanic patients and 22.5% of White non-Hispanic patients underwent emergency surgery. On multivariable logistic regression, Black non-Hispanic race was independently associated with a 5.8 (95% CI, 0.3-11.3) percentage point increased risk of emergency surgery compared with White non-Hispanic race. Patients who underwent emergency surgery were significantly less likely to have preoperative carcinoembryonic antigen measurement, staging for rectal cancer, and wound/ostomy consultation. Patients who underwent emergency surgery had a higher incidence of 30-day mortality (5.5% vs 1.0%, P <0.001), positive surgical margins (11.1% vs 4.9%, P <0.001), complications (29.2% vs 16.0%, P <0.001), readmissions (12.5% vs 9.6%, P =0.005), and reoperations (12.2% vs 8.2%, P <0.001). CONCLUSIONS Among patients with colorectal cancer, Black non-Hispanic patients were more likely to undergo emergency surgery than White non-Hispanic patients, suggesting they may face barriers to timely screening and evaluation. Undergoing emergency surgery was associated with incomplete oncologic evaluation, increased incidence of postoperative complications including mortality, and increased surgical margin positivity. These results suggest that racial and ethnic differences in the diagnosis and treatment of colorectal cancer impact near-term and long-term outcomes.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Samantha Hendren
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Minal Patel
- School of Public Health, University of Michigan, Ann Arbor, MI
| | | | - Matthew Wixson
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | | | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Mark C Bicket
- School of Public Health, University of Michigan, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Opioid Prescriging Engagement Network, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI
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Silver CM, Yang AD, Shan Y, Love R, Prachand VN, Cradock KA, Johnson J, Halverson AL, Merkow RP, McGee MF, Bilimoria KY. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg 2023; 237:128-138. [PMID: 36919951 DOI: 10.1097/xcs.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.
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Affiliation(s)
- Casey M Silver
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
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11
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Gaither M, Eldin M, Haynes AB. Sustainable Quality Improvement Through Statewide Collaboratives. ANNALS OF SURGERY OPEN 2023; 4:e293. [PMID: 37601468 PMCID: PMC10431294 DOI: 10.1097/as9.0000000000000293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- Morgan Gaither
- From the Department of Surgery and Perioperative Care, Dell Medical School, University of Texas Austin, Austin TX
| | - Maya Eldin
- From the Department of Surgery and Perioperative Care, Dell Medical School, University of Texas Austin, Austin TX
| | - Alex B Haynes
- From the Department of Surgery and Perioperative Care, Dell Medical School, University of Texas Austin, Austin TX
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12
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Vetterlein MW, Trinh QD, Seisen T. Re: NIHR Global Research Health Unit on Global Surgery. Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection (ChEETAh): A Pragmatic, Cluster-randomised Trial in Seven Low-income and Middle-income Countries. Lancet 2022;400:1767-76. Eur Urol 2023; 83:e158. [PMID: 36870798 DOI: 10.1016/j.eururo.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/14/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Thomas Seisen
- Department of Urology, Pitié Salpêtrière Hospital, APHP, Sorbonne University, GRC5 5, Predictive Onco-Urology, Paris, France.
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Howard R, Brown CS, Lai YL, Gunaseelan V, Brummett CM, Englesbe M, Waljee J, Bicket MC. Postoperative Opioid Prescribing and New Persistent Opioid Use: The Risk of Excessive Prescribing. Ann Surg 2023; 277:e1225-e1231. [PMID: 35129474 PMCID: PMC10537242 DOI: 10.1097/sla.0000000000005392] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the association between postoperative opioid prescribing and new persistent opioid use. SUMMARY BACKGROUND DATA Opioid-nave patients who develop new persistent opioid use after surgery are at increased risk of opioid-related morbidity and mortality. However, the extent to which postoperative opioid prescribing is associated with persistent postoperative opioid use is unclear. METHODS Retrospective study of opioid-naïve adults undergoing surgery in Michigan from 1/1/2017 to 10/31/2019. Postoperative opioid prescriptions were identified using a statewide clinical registry and prescription fills were identified using Michigan's prescription drug monitoring program. The primary outcome was new persistent opioid use, defined as filling at least 1 opioid prescription between post-discharge days 4 to 90 and filling at least 1 opioid prescription between post-discharge days 91 to 180. RESULTS A total of 37,654 patients underwent surgery with a mean age of 52.2 (16.7) years and 20,923 (55.6%) female patients. A total of 31,920 (84.8%) patients were prescribed opioids at discharge. Six hundred twenty-two (1.7%) patients developed new persistent opioid use after surgery. Being prescribed an opioid at discharge was not associated with new persistent opioid use [adjusted odds ratio (aOR) 0.88 (95% confidence interval (CI) 0.71-1.09)]. However, among patients prescribed an opioid, patients prescribed the second largest [12 (interquartile range (IQR) 3) pills] and largest [20 (IQR 7) pills] quartiles of prescription size had higher odds of new persistent opioid use compared to patients prescribed the smallest quartile [7 (IQR 1) pills] of prescription size [aOR 1.39 (95% CI 1.04-1.86) andaOR 1.97 (95% CI 1.442.70), respectively]. CONCLUSIONS In a cohort of opioid-naïve patients undergoing common surgical procedures, the risk of new persistent opioid use increased with the size of the prescription. This suggests that while opioid prescriptions in and of themselves may not place patients at risk of long-term opioid use, excessive prescribing does. Consequently, these findings support ongoing efforts to mitigate excessive opioid prescribing after surgery to reduce opioid-related harms.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
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Mackow AK, Macias CG, Rangel SJ, Fallat ME. Children's surgery verification and value-based care in pediatric surgery. Semin Pediatr Surg 2023; 32:151277. [PMID: 37164817 DOI: 10.1016/j.sempedsurg.2023.151277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.
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Affiliation(s)
| | - Charles G Macias
- University Hospitals Cleveland Medical Center/ Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | - Mary E Fallat
- University of Louisville School of Medicine/ Norton Children's Hospital, Louisville, KY, USA
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15
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Keane OA, Lally KP, Kelley-Quon LI. Rise of pediatric surgery collaboratives to facilitate quality improvement. Semin Pediatr Surg 2023; 32:151278. [PMID: 37156645 DOI: 10.1016/j.sempedsurg.2023.151278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Broad changes in pediatric surgical care delivery are limited by the rarity of pediatric surgical diseases and the geographic dispersion of pediatric surgical care across different hospital types. Pediatric surgical collaboratives and consortiums can provide the patient sample size, research resources, and infrastructure to advance clinical care for children with who require surgery. Additionally, collaboratives can bring together experts and exemplar institutions to overcome barriers to pediatric surgical research to advance quality surgical care. Despite challenges to collaboration, many successful pediatric surgical collaboratives emerged in the last decade and continue to push the field forward towards high-quality, evidence-based care and improved outcomes. This review will discuss the need for continued research and quality improvement collaboratives in pediatric surgery, identify challenges faced when building collaboratives, and introduce future directions to expand impact.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Department of Surgery, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Department of Surgery, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Wanamaker BL, Shoaib A, Seth M, Sukul D, Mamas MA, Gurm HS. Comparative analysis of percutaneous revascularization practice in the United States and the United Kingdom: Insights from the BMC2 and BCIS databases. Catheter Cardiovasc Interv 2023; 101:495-504. [PMID: 36758556 DOI: 10.1002/ccd.30567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/22/2022] [Accepted: 12/25/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND International registry comparisons provide insight into regional differences in clinical practice patterns, procedural outcomes, and general trends in population health and resource utilization in percutaneous coronary intervention (PCI). We sought to compare data from a state-wide PCI registry in the United States with a national registry from the United Kingdom (UK). METHODS We analyzed all PCI cases from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium and the British Cardiovascular Intervention Society registries from 2010 to 2017. Procedural characteristics and in-hospital outcomes were stratified by PCI indication. RESULTS A total of 248,283 cases were performed in Michigan and 773,083 in the United Kingdom during the study period. The proportion of patients with a prior diagnosis of diabetes in Michigan was nearly double that in the United Kingdom (38.9% vs. 21.0%). PCI for ST-elevation myocardial infarction was more frequent in the UK (25% UK vs. 14.3% Michigan). Radial access increased in both registries, reaching 86.8% in the United Kingdom versus 45.1% in Michigan during the final study year. Mechanical support utilization was divergent, falling to 0.9% of cases in the United Kingdom and rising to 3.95% of cases in Michigan in 2017. Unadjusted crude mortality rates were similar in the two cohorts, with higher rates of post-PCI transfusion and other complications in the Michigan population. CONCLUSIONS In a real-world comparison using PCI registries from the US and UK, notable findings include marked differences in the prevalence of diabetes and other comorbidities, a greater proportion of primary PCI with more robust adoption of transradial PCI in the United Kingdom, and divergent trends in mechanical support with increasing use in Michigan.
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Affiliation(s)
- Brett L Wanamaker
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK.,Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK.,Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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17
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Application of Component Separation and Short-Term Outcomes in Ventral Hernia Repairs. J Surg Res 2023; 282:1-8. [PMID: 36244222 DOI: 10.1016/j.jss.2022.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Component separation (CS) techniques have evolved in recent years. How surgeons apply the various CS techniques, anterior component separation (aCS) versus posterior component separation (pCS), by patient and hernia-specific factors remain unknown in the general population. Improving the quality of ventral hernia repair (VHR) on a large scale requires an understanding of current practice variations and how these variations ultimately affect patient care. In this study, we examine the application of CS techniques and the associated short-term outcomes while taking into consideration patient and hernia-specific factors. METHODS We retrospectively reviewed a clinically rich statewide hernia registry, the Michigan Surgical Quality Collaborative Hernia Registry, of persons older than 18 y who underwent VHR between January 2020 and July 2021. The exposure of interest was the use of CS. Our primary outcome was a composite end point of 30-d adverse events including any complication, emergency department visit, readmission, and reoperation. Our secondary outcome was surgical site infection (SSI). Multivariable logistic regression examined the association of CS use, 30-d adverse events, and SSI with patient-, hernia-, and operative-specific variables. We performed a sensitivity analysis evaluating for differences in application and outcomes of the posterior and aCS techniques. RESULTS A total of 1319 patients underwent VHR, with a median age (interquartile range) of 55 y (22), 641 (49%) female patients, and a median body mass index of 32 (9) kg/m2. CS was used in 138 (11%) patients, of which 101 (73%) were pCS and 37 (27%) were aCS. Compared to patients without CS, patients undergoing a CS had larger median hernia widths (2.5 cm (range 0.01-23 cm) versus 8 cm (1-30 cm), P < 0.001). Of the CS cases, 49 (36%) performed in hernias less than 6 cm in size. Following multivariate regression, factors independently associated with the use of a CS were diabetes (odds ratio [OR]: 2.00, 95% confidence interval [CI]: 1.19-3.36), previous hernia repair (OR: 1.88, 95% CI: 1.20-2.96), hernia width (OR: 1.28, 95% CI: 1.22-1.34), and an open approach (OR: 3.83, 95% CI: 2.24-6.53). Compared to patients not having a CS, use of a CS was associated with increased odds of 30-d adverse events (OR: 1.88 95% CI: 1.13-3.12) but was not associated with SSI (OR: 1.95, 95% CI: 0.74-4.63). Regression analysis demonstrated no differences in 30-d adverse events or SSI between the pCS and aCS techniques. CONCLUSIONS This is the first population-level report of patients undergoing VHR with concurrent posterior or aCS. These data suggest wide variation in the application of CS in VHR and raises a concern for potential overutilization in smaller hernias. Continued analysis of CS application and the associated outcomes, specifically recurrence, is necessary and underway.
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Abstract
OBJECTIVE To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery. SUMMARY BACKGROUND DATA Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low. METHODS Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending postoperative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting body mass index and weight, surgery date, and procedure. Preintervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the 2 historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted differ-ence-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured postoperative months 1, 3, 6, and 12. RESULTS One hundred ten program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 preinter-vention patients and 327 postintervention patients. In difference-in-differ-ences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P <0.0001), 3months (+29.4%, P <0.0001), and 6 months (+16.4%, P <0.0001), but not at 12 months. There were no statistically significant differences in excess weight loss. CONCLUSIONS A financial incentives program significantly increased follow-up after bariatric surgery for up to 6 months, but did not increase weight loss. Our study supports use of incentivized approaches as one way to improve postoperative follow-up, but may not translate into greater weight loss without additional supports.
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Spehar SM, Seth M, Henke P, Alaswad K, Schreiber T, Berman A, Syrjamaki J, Ali OE, Bader Y, Nerenz D, Gurm H, Sukul D. Race and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Am Heart J 2023; 255:106-116. [PMID: 36216076 DOI: 10.1016/j.ahj.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/28/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Current studies show similar in-hospital outcomes following percutaneous coronary intervention (PCI) between Black and White patients. Long-term outcomes and the role of individual and community-level socioeconomic factors in differential risk are less understood. METHODS We linked clinical registry data from PCIs performed between January, 2013 and March, 2018 at 48 Michigan hospitals to Medicare Fee-for-service claims. We analyzed patients of Black and White race. We used propensity score matching and logistic regression models to estimate the odds of 90-day readmission and Cox regression to evaluate the risk of postdischarge mortality. We used mediation analysis to evaluate the proportion of association mediated by socioeconomic factors. RESULTS Of the 29,317 patients included in this study, 10.28% were Black and 89.72% were White. There were minimal differences between groups regarding post-PCI in-hospital outcomes. Compared with White patients, Black patients were more likely to be readmitted within 90-days of discharge (adjusted OR 1.62, 95% CI [1.32-2.00]) and had significantly higher risk of all-cause mortality (adjusted HR 1.45, 95% CI 1.30-1.61) when adjusting for age and gender. These associations were significantly mediated by dual eligibility (proportion mediated [PM] for readmission: 11.0%; mortality: 21.1%); dual eligibility and economic well-being of the patient's community (PM for readmission: 22.3%; mortality: 43.0%); and dual eligibility, economic well-being of the community, and baseline clinical characteristics (PM for readmission: 45.0%; mortality: 87.8%). CONCLUSIONS Black patients had a higher risk of 90-day readmission and cumulative mortality following PCI compared with White patients. Associations were mediated by dual eligibility, community economic well-being, and traditional cardiovascular risk factors. Our study highlights the need for improved upstream care and streamlined postdischarge care pathways as potential strategies to improve health care disparities in cardiovascular disease.
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Affiliation(s)
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Peter Henke
- Department of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | | | | | | | - John Syrjamaki
- Michigan Value Collaborative at Michigan Medicine, Ann Arbor, MI
| | - Omar E Ali
- Detroit Medical Center Heart Hospital, Detroit, MI
| | - Yousef Bader
- McLaren Bay Regional Heart and Vascular, Bay City, MI
| | - David Nerenz
- Henry Ford Health System Center for Health Policy and Health Services Research, Detroit, MI
| | - Hitinder Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI.
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Varban OA. Comment on: Bariatric surgeon perceptions of the safety of same-day sleeve gastrectomy in the state of Massachusetts. Surg Obes Relat Dis 2022; 19:457-458. [PMID: 36585330 DOI: 10.1016/j.soard.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Oliver A Varban
- Department of Surgery, Bariatric Surgery, and Weight Management, Henry Ford Hospital, Detroit, Michigan
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Howard R, Brown CS, Lai YL, Gunaseelan V, Chua KP, Brummett C, Englesbe M, Waljee J, Bicket MC. The Association of Postoperative Opioid Prescriptions with Patient Outcomes. Ann Surg 2022; 276:e1076-e1082. [PMID: 34091508 PMCID: PMC8787466 DOI: 10.1097/sla.0000000000004965] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids. SUMMARY OF BACKGROUND DATA Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks. METHODS We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups. RESULTS In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids ( P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%- 85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)]. CONCLUSIONS Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Vidhya Gunaseelan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Kao-Ping Chua
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Chad Brummett
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
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22
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Carlin AM, Varban OA, Ehlers AP, Bonham AJ, Ghaferi AA, Finks JF. Independent predictors and timing of portomesenteric vein thrombosis after bariatric surgery. Surg Obes Relat Dis 2022; 18:1385-1391. [PMID: 36198496 DOI: 10.1016/j.soard.2022.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/09/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Portomesenteric vein thrombosis (PVT) is a rare complication following bariatric surgery but can result in severe morbidity as well as death. OBJECTIVE Identification of risk factors for PVT to facilitate targeted management strategies to reduce incidence. SETTING Prospective, statewide bariatric-specific clinical registry. METHODS We identified all patients who underwent primary bariatric surgery between June 2006 and November 2021 (n = 102,869). Patient characteristics, procedure type, operative details, and 30-day postoperative complications were analyzed with multivariable logistic regression to evaluate for independent predictors of PVT. RESULTS A total of 117 patients (.11%) developed a postoperative PVT, with 6 (5.1%) associated deaths. The majority of PVTs occurred in patients who underwent sleeve gastrectomy (109 patients; 93.2%), and the PVT occurred most commonly during the second (37%), third (31%), and fourth weeks (23%) after surgery. Independent risk factors for PVT included a prior history of venous thromboembolism (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.64-5.98; P = .0005), liver disorder (OR = 2.3; 95% CI: 1.36-4.00; P = .0021), undergoing sleeve gastrectomy (OR = 12.4; 95% CI: 4.98-30.69; P < .0001), and postoperative complications including obstruction (OR = 12.5; 95% CI: 4.65-33.77; P < .0001), leak (OR = 7.9; 95% CI: 2.76-22.64; P = .0001), and hemorrhage (OR = 7.6; 95% CI: 3.57-16.06; P < .0001). CONCLUSIONS Independent predictors of PVT include a prior history of venous thromboembolism, liver disease, undergoing sleeve gastrectomy, and experiencing a serious postoperative complication. Given that the incidence of PVT is most common within the first month after surgery, extending postdischarge chemoprophylaxis during this time frame is advised for patients with increased risk.
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Affiliation(s)
- Arthur M Carlin
- Department of Surgery, Henry Ford Health, Detroit, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan.
| | - Oliver A Varban
- Department of Surgery, Henry Ford Health, Detroit, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Anne P Ehlers
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Aaron J Bonham
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Jonathan F Finks
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan; Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
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Solano QP, Howard R, Mullens CL, Ehlers AP, Delaney LD, Fry B, Shen M, Englesbe M, Dimick J, Telem D. The impact of frailty on ventral hernia repair outcomes in a statewide database. Surg Endosc 2022:10.1007/s00464-022-09626-8. [PMCID: PMC9640794 DOI: 10.1007/s00464-022-09626-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/11/2022] [Indexed: 11/09/2022]
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Thompson MP, Yaser JM, Forrest A, Keteyian SJ, Sukul D. Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK. J Cardiopulm Rehabil Prev 2022; 42:E75-E81. [PMID: 35831233 PMCID: PMC10069950 DOI: 10.1097/hcr.0000000000000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation. METHODS Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement. RESULTS A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. CONCLUSIONS This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.
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Affiliation(s)
- Michael P Thompson
- Section of Health Services Research and Quality, Department of Cardiac Surgery (Dr Thompson) and Division of Cardiovascular Medicine, Department of Internal Medicine (Dr Sukul), Michigan Medicine, Ann Arbor; Michigan Value Collaborative, Ann Arbor (Dr Thompson and Ms Yaser); Blue Cross Blue Shield of Michigan Cardiovascular Consortium, Ann Arbor (Ms Forrest and Dr Sukul); and Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Dr Keteyian)
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Schumacher JR, Lawson EH, Kong AL, Weber JJ, May J, Landercasper J, Hanlon B, Marka N, Venkatesh M, Cartmill RS, Pavuluri Quamme S, Nikolay C, Greenberg CC. A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery. Ann Surg 2022; 276:665-672. [PMID: 35837946 PMCID: PMC9529150 DOI: 10.1097/sla.0000000000005590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.
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Affiliation(s)
| | - Elise H Lawson
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Amanda L Kong
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jeanette May
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Bret Hanlon
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Nicholas Marka
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Randi S Cartmill
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Connor Nikolay
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
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Ehlers AP, Bonham AJ, Ghaferi AA, Finks JF, Carlin AM, Varban OA. Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy. Surg Endosc 2022; 36:6815-6821. [PMID: 35854122 DOI: 10.1007/s00464-021-08970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/22/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Repairing a hiatal hernia at the time of laparoscopic sleeve gastrectomy (SG) can reduce or even prevent gastroesophageal reflux disease (GERD) symptoms in the post-operative period. Several different hiatal hernia repair techniques have been described but their impact on GERD symptoms after SG is unclear. METHODS Surgeons (n = 74) participating in a statewide quality collaborative were surveyed on their typical technique for repair of hiatal hernias during SG. Options included posterior repair with mesh (PRM), posterior repair (PR), and anterior repair (AR). Patients who underwent SG with concurrent hiatal hernia repair (n = 7883) were compared according to their surgeon's reported technique. Patient characteristics, baseline and 1-year GERD health-related quality of life surveys, weight loss and 30-day risk-adjusted complications were analyzed. RESULTS The most common technique reported by surgeons for hiatal hernia repair was PR (n = 64, 85.3%), followed by PRM (n = 7, 9.3%) and AR (n = 4, 5.3%). Patients who underwent SG by surgeons who perform AR had lower rates of baseline GERD diagnosis (AR 55.3%, PR 59.5%, PRM 64.8%, p < 0.01), but were more likely to experience worsening GERD symptoms at 1 year (AR 29.8%, PR 28.7%, PRM 28.2%, p < 0.0001), despite similar weight loss (AR 29.8%, PR 28.7%, PRM 28.2%, p = 0.08). Satisfaction with GERD symptoms at 1 year was high (AR 73.2%, PR 76.3%, PRM 75.7%, p = 0.43), and risk-adjusted 30-day outcomes were similar among all groups. CONCLUSIONS Patients undergoing SG with concurrent hiatal hernia repair by surgeons who typically perform an AR were more likely to report worsening GERD at 1 year despite excellent weight loss. Surgeons who typically performed an AR had nearly one-half of their patients report increased GERD severity after surgery despite similar weight loss. While GERD symptom control may be multifactorial, technical approach to hiatal hernia repair at the time of SG may play a role and a posterior repair is recommended.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA.
| | - Aaron J Bonham
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Jonathan F Finks
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Oliver A Varban
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
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Ehlers AP, Howard R, Delaney LD, Solano Q, Telem DA. Variation in approach for small (< 2 cm) ventral hernias across a statewide quality improvement collaborative. Surg Endosc 2022; 36:6760-6766. [PMID: 35854123 DOI: 10.1007/s00464-021-08957-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/09/2021] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Operative technique for hernias < 2 cm is highly controversial. Limited data exist about this practice at a population level. Within this context we sought to describe practice patterns and use of mesh among patients undergoing repair of small hernias within the setting of a statewide quality improvement collaborative. METHODS Retrospective cohort study of patients undergoing hernia repair in the Michigan Surgical Quality Collaborative Hernia Registry was conducted. Patients who underwent repair of a hernia < 2 cm from January 1, 2020 to July 8, 2021 were included. Descriptive statistics were performed to describe cohort characteristics and compare patients who did and did not receive mesh. Logistic regression was performed to estimate the odds of receiving mesh after accounting for patient and hernia characteristics. RESULTS Among 570 patients, 56.1% (n = 320) had mesh placed. Most repairs were conducted via open approach (n = 437, 76.5%). Patients who received mesh were older (51.8 vs 48.6, p < 0.01), had higher BMI (31.7 vs 30.0, p < 0.01), were more often ASA Class III (35.9% vs 24.4%, p < 0.01), more often had diabetes (15.9% vs 10.0%, 0.04) and hypertension (44.7% vs 30.4%, p < 0.01), and had higher hernia width (1.2 cm vs 1.0 cm, p < 0.0001). After adjustment, ASA Class III (aOR 3.41, 95% CI 1.31-8.89), current smoking status (aOR 1.81, 95% CI 1.04-3.18), higher mean hernia width (aOR 5.68, 95% CI 2.97-10.85), and laparoscopic (aOR 12.9, 95% CI 5.02-32.96) or robotic (aOR 24.3, 95% CI 6.96-84.96) were associated with mesh use, while COPD (aOR 0.36, 95% CI 0.07-0.96) was associated with less mesh use. CONCLUSIONS Use of mesh for small hernias remains controversial. We found that patients who had mesh placed at the time of surgery were potentially patients at higher risk for complications. The decision to use mesh may be driven by patient-related factors that predispose to complications and operative recurrence rather than evidence indicating that it is superior in this population.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Ryan Howard
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lia D Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Quintin Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
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Independent Predictors of Discontinuation of Diabetic Medication after Sleeve Gastrectomy and Gastric Bypass. J Am Coll Surg 2022; 235:654-665. [PMID: 35752876 DOI: 10.1097/xcs.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Both gastric bypass and sleeve gastrectomy can induce diabetes remission. However, deciding which procedure to perform is challenging since remission rates and morbidity can vary depending on patient factors as well as disease severity. METHODS Using a state-wide bariatric-specific data registry we evaluated all patients undergoing sleeve gastrectomy and gastric bypass between 2006-2019 who reported taking either oral diabetic medication alone or who were on insulin prior to surgery and who also had 1-year follow-up (n=11,664). Multivariate regression was used to identify independent predictors for discontinuation of oral diabetic medication or insulin, respectively, and risk-adjusted complication rates were compared between procedure types among each group. RESULTS At 1-year after surgery, 85.7% of patients reported discontinuation of oral diabetic medication and 66.6% reported discontinuation of insulin. Gastric bypass was an independent predictor for insulin discontinuation (OR 1.17, CI 1.01-1.35, p=0.0329), however procedure type was not associated with discontinuation of oral medication alone. Risk adjusted complication rates were significantly higher after gastric bypass than sleeve gastrectomy, regardless of whether the patient was taking oral diabetic medications alone or was on insulin (11.2% vs 4.8%, p<0.0001 and 12.0% vs 7.4%, p<0.0001, respectively). CONCLUSIONS Patients requiring insulin experience higher rates of insulin discontinuation after gastric bypass but also have significantly higher complication rates when compared to sleeve gastrectomy. However, if patients are on oral diabetic medication alone, rates of medication discontinuation at 1 year are greater than 85% and procedure type is not predictive. Disease severity is an important factor when deciding on the optimal procedure for diabetes.
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Ehlers AP, Vitous CA, Chao GF, Stricklen A, Ross R, Kullgren JT, Ghaferi AA. Female Patient Perceptions on Financial Incentives to Promote Follow-Up After Bariatric Surgery. J Surg Res 2022; 276:195-202. [PMID: 35366424 DOI: 10.1016/j.jss.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery. METHODS This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis. RESULTS Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up. CONCLUSIONS While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan.
| | - C Ann Vitous
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Grace F Chao
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; National Clinician Scholars Program, Veterans Affairs Ann Arbor, Michigan; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Rachel Ross
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Jeffrey T Kullgren
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Departments of Internal Medicine and Health Management and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
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Bamdad MC, Brown CS, Kamdar N, Weng W, Englesbe MJ, Lussiez A. Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy. J Am Coll Surg 2022; 234:300-309. [PMID: 35213493 PMCID: PMC10369366 DOI: 10.1097/xcs.0000000000000063] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy. STUDY DESIGN We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications. RESULTS A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication. CONCLUSIONS This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.
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Affiliation(s)
- Michaela C Bamdad
- From the Department of Surgery, University of Michigan, Ann Arbor, MI
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Ariyo P, Abernathy JH, Hensley NB. Role of Value-Added Care by Cardiothoracic Anesthesiology and Impact on Outcomes After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2022; 26:173-178. [PMID: 35130773 DOI: 10.1177/10892532211048953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The medical community is increasingly aware of the need for high-quality and high-value patient care. Anesthesiologists in particular have long demonstrated leadership in the field of quality and safety. Cardiothoracic anesthesiologists can improve the quality of care delivered to cardiac patients both with anesthesia-specific practices and in a team-based approach with other perioperative care providers. Collecting large volumes of multicentered data to study, measure, and improve anesthesia care is one of the many commitments of cardiothoracic anesthesiologists to this cause. This article reviews this and other aspects of the work of cardiothoracic anesthesiologists to improve value-added care to cardiac patients.
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Affiliation(s)
- Promise Ariyo
- 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Nadia B Hensley
- 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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Guideline-discordant care among females undergoing groin hernia repair: the importance of sex as a biologic variable. Hernia 2022; 26:823-829. [PMID: 35084594 DOI: 10.1007/s10029-021-02543-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/26/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable. METHODS Retrospective cohort study of adults undergoing elective groin hernia repair (2014-2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys. RESULTS Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%, p < 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80-0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%, p = 0.003). CONCLUSIONS Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population.
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Varban OA, Cain-Nielsen AH, Wood MH, Carlin AM, Ghaferi AA, Telem DA. Adopt or Abandon? Surgeon-Specific Trends in Robotic Bariatric Surgery Utilization Between 2010 and 2019. J Laparoendosc Adv Surg Tech A 2022; 32:768-774. [PMID: 35041519 DOI: 10.1089/lap.2021.0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It is unknown if surgeons are more likely to adopt or abandon robotic techniques given that bariatric procedures are already performed by surgeons with advanced laparoscopic skills. Methods: We used a statewide bariatric-specific data registry to evaluate surgeon-specific volumes of robotic bariatric cases between 2010 and 2019. Operative volume, procedure type, and patient characteristics were compared between the highest utilizers of robotic bariatric procedures (adopters) and surgeons who stopped performing robotic cases, despite demonstrating prior use (abandoners). Results: A total of 44 surgeons performed 3149 robotic bariatric procedures in Michigan between 2010 and 2019. Robotic utilization peaked in 2019, representing 7.24% of all bariatric cases. We identified 7 surgeons (16%) who performed 95% of the total number of robotic cases (adopters) and 12 surgeons (27%) who stopped performing bariatric cases during the study period (abandoners). Adopters performed a higher proportion of gastric bypass both robotically (22.9% versus 3.1%, P < .001) and laparoscopically (27.5% versus 15.1%, P < .001), when compared with abandoners. Surgeon experience (no. of years in practice), type of practice (teaching versus nonteaching hospital), and patient populations were similar between groups. Conclusions: Robotic bariatric utilization increased during the study period. The majority of robotic cases were performed by a small number of surgeons who were more likely to perform more complex cases such as gastric bypass in their own practice. Robotic adoption may be influenced by surgeon-specific preferences based upon procedure-specific volumes and may play a greater role in performing more complex surgical procedures in the future.
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Affiliation(s)
- Oliver A Varban
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne H Cain-Nielsen
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael H Wood
- Department of Surgery, Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Amir A Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
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Sukul D, Seth M, Thompson MP, Keteyian SJ, Boyden TF, Syrjamaki JD, Yaser J, Likosky DS, Gurm HS. Hospital and Operator Variation in Cardiac Rehabilitation Referral and Participation After Percutaneous Coronary Intervention: Insights From Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Circ Cardiovasc Qual Outcomes 2021; 14:e008242. [PMID: 34749515 DOI: 10.1161/circoutcomes.121.008242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its established benefit and strong endorsement in international guidelines, cardiac rehabilitation (CR) use remains low. Identifying determinants of CR referral and use may help develop targeted policies and quality improvement efforts. We evaluated the variation in CR referral and use across percutaneous coronary intervention (PCI) hospitals and operators. METHODS We performed a retrospective observational cohort study of all patients who underwent PCI at 48 nonfederal Michigan hospitals between January 1, 2012 and March 31, 2018 and who had their PCI clinical registry record linked to administrative claims data. The primary outcomes included in-hospital CR referral and CR participation, defined as at least one outpatient CR visit within 90 days of discharge. Bayesian hierarchical regression models were fit to evaluate the association between PCI hospital and operator with CR referral and use after adjusting for patient characteristics. RESULTS Among 54 217 patients who underwent PCI, 76.3% received an in-hospital referral for CR, and 27.1% attended CR within 90 days after discharge. There was significant hospital and operator level variation in in-hospital CR referral with median odds ratios of 3.88 (95% credible interval [CI], 3.06-5.42) and 1.64 (95% CI, 1.55-1.75), respectively, and in CR participation with median odds ratios of 1.83 (95% CI, 1.63-2.15) and 1.40 (95% CI, 1.35-1.47), respectively. In-hospital CR referral was significantly associated with an increased likelihood of CR participation (adjusted odds ratio, 1.75 [95% CI, 1.52-2.01]), and this association varied by treating PCI hospital (odds ratio range, 0.92-3.75) and operator (odds ratio range, 1.26-2.82). CONCLUSIONS In-hospital CR referral and 90-day CR use after PCI varied significantly by hospital and operator. The association of in-hospital CR referral with downstream CR use also varied across hospitals and less so across operators suggesting that specific hospitals and operators may more effectively translate CR referrals into downstream use. Understanding the factors that explain this variation will be critical to developing strategies to improve CR participation overall.
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Affiliation(s)
- Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, MI (D.S.. H.S.G.)
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor
| | - Michael P Thompson
- Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor.,Department of Cardiac Surgery (M.P.T., D.S.L.), University of Michigan, Ann Arbor
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Thomas F Boyden
- Division of Cardiology, Spectrum Health, Grand Rapids, MI (T.F.B.)
| | - John D Syrjamaki
- Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor
| | - Jessica Yaser
- Michigan Value Collaborative (M.P.T., J.D.S., J.Y.), University of Michigan, Ann Arbor
| | - Donald S Likosky
- Institute for Healthcare Policy and Innovation (D.S., M.P.T., D.S.L.), University of Michigan, Ann Arbor.,Department of Cardiac Surgery (M.P.T., D.S.L.), University of Michigan, Ann Arbor
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.S., M.S., H.S.G.), University of Michigan, Ann Arbor.,Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, MI (D.S.. H.S.G.)
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Aboagye JK, Haut ER, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Holzmueller CG, Lau BD. Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2011-2019. [PMID: 33879395 DOI: 10.1016/j.jsurg.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN Prospective cohort study. SETTING The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
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Affiliation(s)
- Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Nursing, The Johns Hopkins Hospital; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science; Division of Health Sciences Informatics; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Meloche C, Seth M, Madder RD, Kurlander JE, Yaser J, Chattahi J, Collins J, Lingam N, Arora D, Gurm HS, Sukul D. Percutaneous Coronary Intervention in Patients With a History of Gastrointestinal Bleeding (From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium). Am J Cardiol 2021; 155:9-15. [PMID: 34325106 DOI: 10.1016/j.amjcard.2021.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 01/11/2023]
Abstract
Potent antithrombotic agents are routinely prescribed after percutaneous coronary intervention (PCI) to reduce ischemic complications. However, in patients who are at an increased bleeding risk, this may pose significant risks. We sought to evaluate the association between a history of gastrointestinal bleeding (GIB) and outcomes after PCI. We linked clinical registry data from PCIs performed at 48 Michigan hospitals between 1/2013 and 3/2018 to Medicare claims. We used 1:5 propensity score matching to adjust for patient characteristics. In-hospital outcomes included bleeding, transfusion, stroke or death. Post-discharge outcomes included 90-day all-cause readmission and long-term mortality. Of 30,206 patients, 1.1% had a history of GIB. Patients with a history of GIB were more likely to be older, female, and have more cardiovascular comorbidities. After matching, those with a history of GIB (n = 312) had increased post-procedural transfusions (15.7% vs 8.4%; p < 0.001), bleeding (11.9% vs 5.2%; p < 0.001), and major bleeding (2.8% vs 0.6%; p = 0.004). Ninety-day readmission rates were similar among those with and without a history of GIB (34.3% vs 31.3%; p = 0.318). There was no significant difference in post-discharge survival (1 year: 78% vs 80%; p = 0.217; 5 years: 54% vs 51%; p = 0.189). In conclusion, after adjusting for baseline characteristics, patients with a history of GIB had increased risk of post-PCI in-hospital bleeding complications. However, a history of GIB was not significantly associated with 90-day readmission or long-term survival.
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Affiliation(s)
- Chelsea Meloche
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | - Jacob E Kurlander
- Division of Gastroenterology, Department of Internal Medicine, MIchigan Medicine, Ann Arbor, Michigan
| | - Jessica Yaser
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Joseph Chattahi
- Division of Cardiology, Department of Internal Medicine, Beaumont Hospital, Dearborn, Michigan
| | - John Collins
- Department of Cardiology, Ascension Medical Group, St Mary's Saginaw, Saginaw, Michigan
| | - Natesh Lingam
- Department of Cardiology, Henry Ford Macomb Hospitals, Clinton Township, Michigan
| | - Dilip Arora
- Department of Cardiology, Spectrum Health Lakeland, Saint Joseph, Michigan
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan.
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Beaulieu RJ, Albright J, Jeruzal E, Mansour MA, Aziz A, Mouawad NJ, Osborne NH, Henke PK. A statewide quality improvement collaborative significantly improves quality metric adherence and physician engagement in vascular surgery. J Vasc Surg 2021; 75:301-307. [PMID: 34481901 DOI: 10.1016/j.jvs.2021.07.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Quality improvement national registries provide structured, clinically relevant outcome and process-of-care data to practitioners-with regional meetings to disseminate best practices. However, whether a quality improvement collaborative affects processes of care is less clear. We examined the effects of a statewide hospital collaborative on the adherence rates to best practice guidelines in vascular surgery. METHODS A large statewide retrospective quality improvement database was reviewed for 2013 to 2019. Hospitals participating in the quality improvement collaborative were required to submit adherence and outcomes data and meet semiannually. They received an incentive through a pay for participation model. The aggregate adherence rates among all hospitals were calculated and compared. RESULTS A total of 39 hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, the hospital systems improved every year of participation in the collaborative across most "best practice" domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.76-1.79; P < .001), intraoperative antibiotic redosing (OR, 1.09; 95% CI, 1.02-1.17; P = .018), statin use at discharge for appropriate patients (OR, 1.18; 95% CI, 1.16-1.2; P < .001), and reducing transfusions for asymptomatic patients with hemoglobin >8 mg/dL (OR, 0.66; 95% CI, 0.66-0.66; P < .001). The use of antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not affect adherence. The adherence rates exceeded the professional society mean rates for guideline adherence. CONCLUSIONS The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to "best practice" guidelines across a large, heterogeneous group of hospitals.
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Affiliation(s)
| | - Jeremy Albright
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Erin Jeruzal
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - M Ashraf Mansour
- Department of Surgery, Spectrum Health Medical Group, Grand Rapids, Mich
| | - Abdulhameed Aziz
- Department of Surgery, St Joseph Mercy Health Center, Ann Arbor, Mich
| | | | | | - Peter K Henke
- Department of Surgery, University of Michigan, Ann Arbor, Mich
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Yoo SGK, Seth M, Vaduganathan M, Ruwende C, Karve M, Shah I, Hill T, Gurm HS, Sukul D. Marijuana Use and In-Hospital Outcomes After Percutaneous Coronary Intervention in Michigan, United States. JACC Cardiovasc Interv 2021; 14:1757-1767. [PMID: 34412793 DOI: 10.1016/j.jcin.2021.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 05/26/2021] [Accepted: 06/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the association between reported marijuana use and post-percutaneous coronary intervention (PCI) in-hospital outcomes. BACKGROUND Marijuana use is increasing as more states in the United States legalize its use for recreational and medicinal purposes. Little is known about the frequency of use and relative safety of marijuana among patients presenting for PCI. METHODS The authors analyzed Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry data between January 1, 2013, and September 30, 2016. One-to-one propensity matching and multivariable logistic regression were used to adjust for differences between patients with or without reported marijuana use, and rates of post-PCI complications were compared. RESULTS Among 113,477 patients, 3,970 reported marijuana use. Compared with those without reported marijuana use, patients with reported marijuana use were likely to be younger (53.9 years vs 65.8 years), to use tobacco (73.0% vs 26.8%), to present with ST-segment elevation myocardial infarction (27.3% vs 15.9%), and to have fewer cardiovascular comorbidities. After matching, compared with patients without reported marijuana use, those with reported marijuana use experienced significantly higher risks for bleeding (adjusted odds ratio [aOR]: 1.54; 95% confidence interval [CI]: 1.20-1.97; P < 0.001) and cerebrovascular accident (aOR: 11.01; 95% CI: 1.32-91.67; P = 0.026) and a lower risk for acute kidney injury (aOR: 0.61; 95% CI: 0.42-0.87; P = 0.007). There were no significant differences in risks for transfusion and death. CONCLUSIONS A modest fraction of patients undergoing PCI used marijuana. Reported marijuana use was associated with higher risks for cerebrovascular accident and bleeding and a lower risk for acute kidney injury after PCI. Clinicians and patients should be aware of the higher risk for post-PCI complications in these patients.
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Affiliation(s)
- Sang Gune K Yoo
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Milan Seth
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cyril Ruwende
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | | | - Ibrahim Shah
- McLaren Greater Lansing Hospital, Lansing, Michigan, USA
| | | | - Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Regenbogen SE, Cain-Nielsen AH, Syrjamaki JD, Norton EC. Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals. Ann Surg 2021; 274:199-205. [PMID: 33351489 PMCID: PMC8211908 DOI: 10.1097/sla.0000000000004726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - John D Syrjamaki
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
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Howard R, Ehlers A, Delaney L, Solano Q, Englesbe M, Dimick J, Telem D. Leveraging a statewide quality collaborative to understand population-level hernia care. Am J Surg 2021; 222:1010-1016. [PMID: 34090661 DOI: 10.1016/j.amjsurg.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/09/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns. METHODS Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020. RESULTS 919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was <2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and >10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias <2 cm to 95% of hernias >10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width. CONCLUSIONS A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Anne Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Quintin Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Ann Arbor, MI, USA
| | - Dana Telem
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Ann Arbor, MI, USA.
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Yelavarthy P, Seth M, Pielsticker E, Grines CL, Duvernoy CS, Sukul D, Gurm HS. The DISCO study-Does Interventionalists' Sex impact Coronary Outcomes? Catheter Cardiovasc Interv 2021; 98:E531-E539. [PMID: 34000081 DOI: 10.1002/ccd.29774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/30/2021] [Accepted: 05/03/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI). BACKGROUND Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes. METHODS We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis. RESULTS During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy. CONCLUSIONS We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.
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Affiliation(s)
- Prasanthi Yelavarthy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Cindy L Grines
- Division of Cardiovascular Medicine, Northside Cardiovascular Institute, Atlanta, Georgia, USA
| | - Claire S Duvernoy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
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Jackson TD, Beath T, Ahmad N, Arsenault PP, Maeda A, Schramm D, Moloo H, Nathens A. Committed to Better Outcomes: Reducing Infection after Surgery Across the Ontario Surgical Quality Improvement Network. J Am Coll Surg 2021; 233:204-211. [PMID: 34015457 DOI: 10.1016/j.jamcollsurg.2021.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In 2015, the Ontario Surgical Quality Improvement Network was established to create a community of practice for Ontario hospitals to improve surgical quality. A provincial campaign to decrease postsurgical infections was launched in 2017. STUDY DESIGN Thirty hospitals implemented activities related to the campaign from April 2018 to March 2019. The community of practice was used to disseminate suggested change ideas in each area. Self-reported data from participating hospitals and collaborative-wide aggregate risk-adjusted data from the American College of Surgeons NSQIP were reviewed to determine the impact of the campaign on the rates of postoperative surgical site infections (SSIs), urinary tract infections (UTIs), and pneumonia. RESULTS A total of 24, 8, and 2 hospitals selected SSIs, UTIs, and pneumonia, respectively, as their targets for improvement. Three hospitals selected both SSIs and UTIs, 1 hospital selected SSIs and pneumonia, and 1 hospital selected all 3 indicators as targets. Self-reported data demonstrated that the rates of SSIs and UTIs decreased significantly post campaign from 4.87% to 3.99% (p < 0.0001) and from 3.65% to 1.25% (p = 0.007), respectively. Pneumonia rates also decreased from 1.27% to 1.05%. Overall rates of SSIs, UTIs, and pneumonia across all Ontario Surgical Quality Improvement Network hospitals were reduced from 3.4%, 1.29%, and 0.88% to 3.37%, 1.14%, and 0.84%, respectively. CONCLUSIONS The 1-year campaign resulted in a clinically significant reduction in the rates of SSIs and UTIs, as well as a trend for decrease in pneumonia incidence among participating hospitals. Using a flexible approach with priority setting and leveraging the community of practice for dissemination of change ideas is an effective way of sustaining quality improvement activities.
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Affiliation(s)
- Timothy D Jackson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | | | | | | | - Azusa Maeda
- Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - David Schramm
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Husein Moloo
- Division of General Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Division of General Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of HEalth Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Reese AC, Ginzburg S. The past, present, and future of urological quality improvement collaboratives. Transl Androl Urol 2021; 10:2280-2288. [PMID: 34159110 PMCID: PMC8185671 DOI: 10.21037/tau.2019.10.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Surgical quality improvement collaboratives (QIC) have been established across the nation in numerous specialties. These QICs have shown efficacy in improving the quality, safety and value of care delivered to patients with a wide range of medical conditions. In recent years, urological QICs have emerged, including regional collaboratives such as the Michigan Urological Surgical Improvement Collaborative (MUSIC) and Pennsylvania Urologic Regional Collaborative (PURC), as well as the national American Urological Association Quality Registry Program (AQUA). These urological collaboratives, developed with an initial focus on prostate cancer, have demonstrated an ability to accurately measure prostate cancer outcomes, compare these outcomes among providers and institutions, and enact change among both patients and providers to optimize outcomes for men with prostate cancer. Physician-led regional collaboratives may be uniquely positioned to respond quickly to the rapidly-evolving healthcare landscape and enact practice and provider-level changes when appropriate. This review describes the historical background, current structure and function, and potential future directions of these urologic QICs.
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Affiliation(s)
- Adam C Reese
- Department of Urology, Lewis Katz School of Medicine, Temple University, PA, USA
| | - Serge Ginzburg
- Department of Urology, Albert Einstein Medical Center, Philadelphia, PA, USA
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Discussion: A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis. Plast Reconstr Surg 2021; 147:34-36. [PMID: 33370045 DOI: 10.1097/prs.0000000000007421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
IMPORTANCE Surgery is a teachable moment, and smoking cessation interventions that coincide with an episode of surgical care are especially effective. Implementing these interventions at a large scale requires understanding the prevalence and characteristics of smoking among surgical patients. OBJECTIVES To describe the prevalence of smoking in a population of patients undergoing common surgical procedures and to identify any clinical or demographic characteristics associated with smoking. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included all adult patients (aged ≥18 years) in a statewide registry who underwent general and vascular surgical procedures from 2012 to 2019 at 70 hospitals in Michigan. Data analysis was conducted from August to October 2020. EXPOSURES Undergoing a surgical procedure in any of the following categories: appendectomy, cholecystectomy, colon procedures, gastric or esophageal procedures, hepatopancreatobiliary procedures, hernia repair, small-bowel procedures, hysterectomy, vascular procedures, thyroidectomy, and other unspecific abdominal procedures. MAIN OUTCOMES AND MEASURES The prevalence of smoking prior to surgery, defined as cigarette use in the year prior to surgery, obtained from medical record review. Multivariable logistic regression was performed to analyze smoking prevalence based on insurance type and year of surgery while adjusting for demographic and clinical factors, including age, sex, race/ethnicity (determined from the medical record), insurance type, geographic region, comorbidities (ie, hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic steroid use, and obstructive sleep apnea), American Society of Anesthesiologists classification, admission status, surgical priority, procedure type, and year of surgery. RESULTS From 2012 to 2019, 328 578 patients underwent surgery and were included in analysis. Mean (SD) age was 54.0 (17.0) years, and 197 501 patients (60.1%) were women. The overall prevalence of smoking was 24.1% (79 152 patients). Prevalence varied regionally from 21.5% (95% CI, 21.0%-21.9%; 6686 of 31 172 patients) in southeast Michigan to 28.0% (95% CI, 27.1%-28.9%; 2696 of 9614 patients) in northeast Michigan. When adjusting for clinical and demographic factors, there were greater odds of smoking among patients with Medicaid (odds ratio [OR], 2.75; 95% CI, 2.69-2.82) and patients without insurance (OR, 2.21; 95% CI, 2.10-2.33) compared with patients with private insurance. Among procedure categories, patients undergoing vascular surgery had greater odds of smoking (OR, 3.24; 95% CI, 3.11-3.38) than those undergoing cholecystectomy. Compared with 2012, the adjusted odds of smoking decreased significantly each year (eg, 2019: OR, 0.78; 95% CI, 0.74-0.81). In 2019, the adjusted prevalence of smoking was 22.3% (95% CI, 22.0%-22.7%) among all patients, 43.0% (95% CI, 42.4%-43.6%) among patients with Medicaid, and 36.3% (95% CI, 35.2%-37.4%) among patients without insurance. CONCLUSIONS AND RELEVANCE In a statewide population of surgical patients, nearly one-quarter of patients smoked cigarettes, which is higher than the national average. The prevalence of smoking was especially high among patients without insurance and among those receiving Medicaid. Given the established association between undergoing a major surgical procedure and health behavior change, targeted smoking cessation interventions at the time of surgery may be an effective strategy to improve population health, especially among at-risk patient groups.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Kushal Singh
- Michigan Surgical Quality Collaborative, Ann Arbor
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Surgical Quality Collaborative, Ann Arbor
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Sutton NR, Seth M, Madder RD, Sukul D, Dixon SR, Cannon LA, Gurm HS. Comparative Safety of Bioabsorbable Polymer Everolimus-Eluting, Durable Polymer Everolimus-Eluting, and Durable Polymer Zotarolimus-Eluting Stents in Contemporary Clinical Practice. Circ Cardiovasc Interv 2021; 14:e009850. [PMID: 33626898 DOI: 10.1161/circinterventions.120.009850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (N.R.S., M.S., D.S., H.S.G.)
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (N.R.S., M.S., D.S., H.S.G.)
| | - Ryan D Madder
- Division of Cardiology, Spectrum Health, Grand Rapids, MI (R.D.M.)
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (N.R.S., M.S., D.S., H.S.G.)
- Department of Medicine, Section of Cardiology, Veterans Affairs Medical Center, Ann Arbor, MI (D.S., H.S.G.)
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, MI (S.R.D.)
| | - Louis A Cannon
- Cardiac and Vascular Research Center of Northern Michigan, Petoskey (L.A.C.)
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (N.R.S., M.S., D.S., H.S.G.)
- Department of Medicine, Section of Cardiology, Veterans Affairs Medical Center, Ann Arbor, MI (D.S., H.S.G.)
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Lockett MA, Mauldin PD, Zhang J, Marsden JE, Taber DJ, Gebregziabher M, Chung C, Hebbar P, Adams L, Baliga PK. Facilitated Regional Collaboration and In-Hospital Surgical Complication. J Am Coll Surg 2020; 232:536-543. [PMID: 33383216 DOI: 10.1016/j.jamcollsurg.2020.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina. STUDY DESIGN In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics. RESULTS The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative. CONCLUSIONS Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative.
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Affiliation(s)
- Mark A Lockett
- Medical University of South Carolina, College of Medicine, Charleston, SC.
| | - Patrick D Mauldin
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Jingwen Zhang
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Justin E Marsden
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - David J Taber
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | | | - Catherine Chung
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Preetha Hebbar
- Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Larry Adams
- Health Sciences South Carolina, Columbia, SC
| | - Prabhakar K Baliga
- Medical University of South Carolina, College of Medicine, Charleston, SC
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The influence of tobacco load versus smoking status on outcomes following lobectomy for lung cancer in a statewide quality collaborative. J Thorac Cardiovasc Surg 2020; 162:1375-1385.e1. [PMID: 33558118 DOI: 10.1016/j.jtcvs.2020.10.162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer. METHODS Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications. RESULTS The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications. CONCLUSIONS Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes.
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Shah R, Diaz A, Tripepi M, Bagante F, Tsilimigras DI, Machairas N, Sigala F, Moris D, Barreto SG, Pawlik TM. Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition. J Gastrointest Surg 2020; 24:2874-2883. [PMID: 32705613 DOI: 10.1007/s11605-020-04748-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There has been a dramatic increase in worldwide health care spending over the last several decades. Operative procedures and perioperative care in the USA represent some of the most expensive episodes per patient. In view of both the rising cost of health care in general and the rising cost of surgical care specifically, policymakers and stakeholders have sought to identify ways to increase the value-improving quality of care while controlling (or diminishing) costs. In this context, we reviewed data relative to achieving the "value proposition" in the delivery of gastrointestinal surgical care. METHODS The National Library of Medicine online repository (PubMed) was text searched for human studies including "cost," "quality," "outcomes," "health care," "surgery," and "value." Results from this literature framed by the Donabedian conceptual model (identifying structures, processes, and outcomes), and the resulting impact of efforts to improve quality on costs. RESULTS The relationship between quality and costs was nuanced. Better quality care, though associated with better outcomes, was not always reported as concomitant with low costs. Moreover, some centers reported higher costs of surgical care commensurate with higher quality. Conversely, higher costs in health care delivery were not always linked to improved outcomes. While higher quality surgical care can lead to lower costs, higher costs of care were not necessarily associated with better outcomes. Strategies to improve quality, reduce cost, or achieve both simultaneously included regionalization of complex operations to high-volume centers of excellence, overall reduction in complications, introducing evidence-based improvements in perioperative care pathways including as enhanced recovery after surgery (ERAS), and elimination of inefficient or low-value care. CONCLUSIONS The relationship between quality and cost following gastrointestinal surgical procedure is complex. Data from the current study should serve to highlight the various means available to improve the value proposition related to surgery, as well as encourage surgeons to become more engaged in the national conversation around the Triple Aim of better health care quality, lower costs, and improved health care outcomes.
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Affiliation(s)
- Rohan Shah
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - Adrian Diaz
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Marzia Tripepi
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Fragiska Sigala
- Department of Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of HPB Surgery and Liver Transplantation, Royal Free London, London, UK
| | - Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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