1
|
Sheetz KH, Telem DA, Feldman LS. Robotics for Emergency General Surgery-Selecting the Right Tool. JAMA Surg 2024; 159:500. [PMID: 38446439 DOI: 10.1001/jamasurg.2024.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
| | - Dana A Telem
- Department of Surgery, University of Michigan, Ann Arbor
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, Québec, Canada
| |
Collapse
|
2
|
Kalata S, Thumma JR, Sheetz KH. Common Bile Duct Injury in Cholecystectomy-Reply. JAMA Surg 2024; 159:592. [PMID: 38416476 DOI: 10.1001/jamasurg.2023.8084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| |
Collapse
|
3
|
Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg 2023; 158:1303-1310. [PMID: 37728932 PMCID: PMC10512167 DOI: 10.1001/jamasurg.2023.4389] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/10/2023] [Indexed: 09/22/2023]
Abstract
Importance Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. Objective To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. Design, Setting, and Participants This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Exposure Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. Main Outcomes and Measures The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. Results A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). Conclusions and Relevance This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.
Collapse
Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor
- Department of Economics, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Section Editor, JAMA Surgery
| | - Kyle H. Sheetz
- Department of Surgery, University of California, San Francisco
| |
Collapse
|
4
|
Bonner SN, Thumma JR, Dimick JB, Sheetz KH. Trends in Use of Robotic Surgery for Privately Insured Patients and Medicare Fee-for-Service Beneficiaries. JAMA Netw Open 2023; 6:e2315052. [PMID: 37223903 PMCID: PMC10209745 DOI: 10.1001/jamanetworkopen.2023.15052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/11/2023] [Indexed: 05/25/2023] Open
Abstract
This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.
Collapse
Affiliation(s)
- Sidra N. Bonner
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
- National Clinician Scholars Program, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Kyle H. Sheetz
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco
| |
Collapse
|
5
|
Jacobson CE, Brown CS, Sheetz KH, Waits SA. Left digit bias in selection and acceptance of deceased donor organs. Am J Surg 2022; 224:1104-1108. [DOI: 10.1016/j.amjsurg.2022.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/23/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
|
6
|
Schwartzman DA, Sheetz KH, Fendrick AM. Refining the Recipe for Alternative Payment Models for Surgical Care-Importance of Patient Mix and Venue Match. JAMA Netw Open 2021; 4:e2128258. [PMID: 34559234 DOI: 10.1001/jamanetworkopen.2021.28258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Kyle H Sheetz
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - A Mark Fendrick
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| |
Collapse
|
7
|
Brown CS, Waits SA, Englesbe MJ, Sonnenday CJ, Sheetz KH. Associations Among Different Domains of Quality Among US Liver Transplant Programs. JAMA Netw Open 2021; 4:e2118502. [PMID: 34369991 PMCID: PMC8353538 DOI: 10.1001/jamanetworkopen.2021.18502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/21/2021] [Indexed: 12/20/2022] Open
Abstract
Importance US liver transplant programs have traditionally been evaluated on 1-year patient and graft survival. However, there is concern that a narrow focus on recipient outcomes may not incentivize programs to improve in other ways that would benefit patients with end-stage liver disease. Objective To determine the correlation among different potential domains of quality for adult liver transplant programs. Design, Setting, and Participants This retrospective cohort study was conducted from 2014 to 2019 among adult liver transplant programs included in the United Network for Organ Sharing and Scientific Registry of Transplant Recipients program-specific reports. Liver transplant programs in the United States completing at least 10 liver transplants per year were included. Data were analyzed from March 2 to August 13, 2020. Main Outcomes and Measures The potential domains of quality examined included recipient outcomes (1-year graft and patient survival), aggressiveness (ie, marginal graft use, defined as the rate of use of donors with body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 40, age older than 65 years, or deceased by cardiac death), and waiting list management (ie, waiting list mortality). The correlation among measures, aggregated at the center level, was evaluated using linear regression to control for mean Model for End Stage Liver Disease-Sodium score at organ allocation. The extent to which programs were able to achieve high quality across multiple domains was also evaluated. Results Among 114 transplant programs that performed a total of 44 554 transplants, the mean (SD) 1-year graft and patient survival was 90.3% (3.0%) with a total range of 75.9% to 96.6%. The mean (SD) waiting list mortality rate was 16.7 (6.1) deaths per 100 person-years, with a total range of 6.3 to 53.0 deaths per 100 person years. The mean (SD) marginal graft use rate was 15.8 (8.8) donors per 100 transplants, with a total range of 0 to 49.3 donors. There was no correlation between 1-year graft and patient survival and waiting list mortality (β = -0.053; P = .19) or marginal graft use (β = -0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease-Sodium scores. There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures. Conclusions and Relevance This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management. These findings suggest that a program's performance in one domain may be independent and unrelated to its performance on others and that the understanding of factors contributing to these domains is incomplete.
Collapse
Affiliation(s)
- Craig S. Brown
- Department of Surgery, University of Michigan, Ann Arbor
| | - Seth A. Waits
- Department of Surgery, University of Michigan, Ann Arbor
| | | | | | - Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
8
|
Sheetz KH, Gerhardinger L, Ryan AM, Waits SA. Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program : An Observational Study With a Regression Discontinuity Design. Ann Intern Med 2021; 174:1058-1064. [PMID: 34058101 DOI: 10.7326/m20-6662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program. OBJECTIVE To determine whether penalization was associated with improvement in dialysis center quality. DESIGN Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015-2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined. SETTING United States. PARTICIPANTS Outpatient dialysis centers (n = 5830). MEASUREMENTS Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score. RESULTS There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, -2.5 to 3.2 points]) or 2018 (0.3 point [CI, -2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures. LIMITATION The study could not account for how centers respond to penalization. CONCLUSION Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. PRIMARY FUNDING SOURCE None.
Collapse
Affiliation(s)
- Kyle H Sheetz
- University of Michigan, Center for Healthcare Outcomes and Policy, and Center for Evaluating Health Reform, Ann Arbor, Michigan (K.H.S.)
| | | | - Andrew M Ryan
- Center for Healthcare Outcomes and Policy, Center for Evaluating Health Reform, and University of Michigan School of Public Health, Ann Arbor, Michigan (A.M.R.)
| | - Seth A Waits
- University of Michigan and Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan (S.A.W.)
| |
Collapse
|
9
|
Sheetz KH, Norton EC, Dimick JB, Regenbogen SE. Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016. JAMA Surg 2021; 155:41-49. [PMID: 31617874 DOI: 10.1001/jamasurg.2019.4083] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. Objective To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. Design, Setting, and Participants This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. Exposures Receipt of robotic colectomy. Main Outcomes and Measures Incidence of postoperative medical and surgical complications and length of stay. Results A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). Conclusions and Relevance While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor.,Department of Health Management and Policy, University of Michigan, Ann Arbor.,Department of Economics, University of Michigan, Ann Arbor.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor.,Surgical Innovation Editor, JAMA Surgery
| | - Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, School of Medicine, Ann Arbor
| |
Collapse
|
10
|
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| |
Collapse
|
11
|
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| |
Collapse
|
12
|
Sheetz KH, Massarweh NN. Toward IDEAL Adoption of Robotic Surgery Into Clinical Practice-Lessons From Transcatheter Aortic Valve Replacement. JAMA Surg 2021; 156:301-302. [PMID: 33263737 DOI: 10.1001/jamasurg.2020.5542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
13
|
Sheetz KH, Gerhardinger L, Dimick JB, Waits SA. Bariatric Surgery and Long-term Survival in Patients With Obesity and End-stage Kidney Disease. JAMA Surg 2021; 155:581-588. [PMID: 32459318 DOI: 10.1001/jamasurg.2020.0829] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Obesity rates in patients with end-stage kidney disease are rising, contribute to excess morbidity, and limit access to kidney transplant. Despite this, there continues to be controversy around the use of bariatric surgery in this patient population. Objective To determine whether bariatric surgery is associated with improvement in long-term survival among patients with obesity and end-stage kidney disease. Design, Setting, and Participants Retrospective cohort study and secondary analysis of previously collected data from the United States Renal Data System registry (2006-2015). We used Cox proportional hazards analysis to evaluate differences in outcomes for patients receiving bariatric surgery (n = 1597) compared with a matched cohort of nonsurgical patients (n = 4750) receiving usual care. Data were analyzed between September 3, 2019, and November 13, 2019. Exposure Receipt of bariatric surgery. Main Outcomes and Measures All-cause mortality at 5 years. Secondary outcomes included disease-specific mortality and incidence of kidney transplant. Results Surgical and nonsurgical control patients had similar age, demographics, and comorbid disease burden. The mean (SD) age was 49.8 (11.2) years for surgical patients vs 51.7 (11.1) years for nonsurgical patients. Six hundred fifteen surgical patients (38.5%) were black vs 1833 nonsurgical patients (38.6%). Surgery was associated with lower all-cause mortality at 5 years compared with usual care (cumulative incidence, 25.6% vs 39.8%; hazard ratio, 0.69, 95% CI, 0.60-0.78). This was driven by lower mortality from cardiovascular causes at 5 years for patients undergoing bariatric surgery compared with nonsurgical control patients (cumulative incidence, 8.4% vs 17.2%; hazard ratio, 0.51; 95% CI, 0.41-0.65). Bariatric surgery was also associated with an increase in kidney transplant at 5 years (cumulative incidence, 33.0% vs 20.4%; hazard ratio, 1.82; 95% CI, 1.58-2.09). However, at 1 year, bariatric surgery was associated with higher all-cause mortality compared with usual care (cumulative incidence, 8.6% vs 7.7%; hazard ratio, 1.45; 95% CI, 1.13-1.85). Conclusions and Relevance Among patients with obesity and end-stage kidney disease, bariatric surgery was associated with lower all-cause mortality compared with usual care. Bariatric surgery was also associated with an increase in kidney transplant. Bariatric surgery may warrant further consideration in the treatment of patients with obesity and end-stage kidney disease.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| |
Collapse
|
14
|
da Costa WL, Tran Cao HS, Sheetz KH, Gu X, Norton EC, Massarweh NN. Comparative Effectiveness of Neoadjuvant Therapy and Upfront Resection for Patients with Resectable Pancreatic Adenocarcinoma: An Instrumental Variable Analysis. Ann Surg Oncol 2020; 28:3186-3195. [PMID: 33174146 DOI: 10.1245/s10434-020-09327-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/17/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is increasingly being used in the management of patients with resectable pancreatic ductal adenocarcinoma (PDAC); however, there is a lack of evidence regarding the benefit among these patients. OBJECTIVE The aim of this study was to evaluate overall survival (OS) in PDAC patients with resectable disease treated with NAT or upfront resection through instrumental variable (IV) analysis. DESIGN A national cohort study of resectable PDAC patients in the National Cancer Data Base (2007-2015) treated with either upfront surgery or resection after NAT. Using multivariable modeling and IV methods, OS was compared between those treated with NAT and upfront resection. The IV was hospital-level NAT utilization in the most recent year prior to treatment. RESULTS The cohort included 16,666 patients (14,012 upfront resection; 2654 NAT) treated at 779 hospitals. Among those treated with upfront resection, 59.9% received any adjuvant therapy. NAT patients had higher median (27.9 months, 95% confidence interval [CI] 26.2-29.1) and 5-year OS (24.1%, 95% CI 21.9-26.3%) compared with those treated with upfront surgery (median 21.2 months, 95% CI 20.7-21.6; 5-year survival 20.9%, 95% CI 20.1-21.7%). After multivariable modeling, NAT was associated with an approximately 20% decrease in the risk of death (hazard ratio [HR] 0.78, 95% CI 0.73-0.84), and this effect was magnified in the IV analysis (HR 0.61, 95% CI 0.47-0.79). CONCLUSIONS In patients with resectable PDAC, NAT is associated with improved survival relative to upfront resection. Given the benefits of multimodality therapy and the challenges in receiving adjuvant therapy, consideration should be given to treating all PDAC patients with NAT.
Collapse
Affiliation(s)
- Wilson Luiz da Costa
- Department of Medicine, Epidemiology, and Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA.
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Xiangjun Gu
- Department of Medicine, Epidemiology, and Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Economics, University of Michigan, Ann Arbor, MI, USA
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
15
|
Sheetz KH, Dimick JB, Englesbe MJ, Ryan AM. Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement. Health Aff (Millwood) 2020; 38:1858-1865. [PMID: 31682507 DOI: 10.1377/hlthaff.2018.05504] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2013 the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the program has been successful in improving patient safety has not been independently evaluated. We used clinical registry data on rates of hospital-acquired conditions in 2010-18 from a large surgical collaborative in Michigan to estimate the impact of the policy. While rates of all such conditions declined from 133.4 per 1,000 discharges in the pre-program period to 122.2 in the post-program period, greater improvements were observed for nontargeted measures. We conclude that the program did not improve patient safety in Michigan beyond existing trends. These findings raise questions about whether the program will lead to improvements in patient safety as intended.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Kyle H. Sheetz is a general surgery resident in the Department of Surgery, University of Michigan Medical School, in Ann Arbor
| | - Justin B Dimick
- Justin B. Dimick is the Frederick A. Coller Professor of Surgery and chair of the Department of Surgery, University of Michigan Medical School
| | - Michael J Englesbe
- Michael J. Englesbe is the Cyrenus G. Darling Sr. M.D. and Cyrenus G. Darling Jr. M.D. Professor of Surgery, Department of Surgery, University of Michigan Medical School
| | - Andrew M Ryan
- Andrew M. Ryan ( amryan@umich. edu ) is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| |
Collapse
|
16
|
Montgomery JR, Cohen JA, Brown CS, Sheetz KH, Chao GF, Waits SA, Telem DA. Perioperative risks of bariatric surgery among patients with and without history of solid organ transplant. Am J Transplant 2020; 20:2530-2539. [PMID: 32243667 PMCID: PMC7838764 DOI: 10.1111/ajt.15883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/05/2020] [Accepted: 03/18/2020] [Indexed: 01/25/2023]
Abstract
Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.
Collapse
Affiliation(s)
| | | | - Craig S. Brown
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Kyle H. Sheetz
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Grace F. Chao
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut,National Clinician Scholars Program, Veterans Affairs, Ann Arbor, Michigan
| | - Seth A. Waits
- Department of Transplant Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Dana A. Telem
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
17
|
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
18
|
Sheetz KH, Chhabra KR, Smith ME, Dimick JB, Nathan H. Association of Discretionary Hospital Volume Standards for High-risk Cancer Surgery With Patient Outcomes and Access, 2005-2016. JAMA Surg 2020; 154:1005-1012. [PMID: 31411663 DOI: 10.1001/jamasurg.2019.3017] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Various clinical societies and patient advocacy organizations continue to encourage minimum volume standards at hospitals that perform certain high-risk operations. Although many clinicians and quality and safety experts believe this can improve outcomes, the extent to which hospitals have responded to these discretionary standards remains unclear. Objective To evaluate the association between short-term clinical outcomes and hospitals' adherence to the Leapfrog Group's minimum volume standards for high-risk cancer surgery. Design, Setting, and Participants Longitudinal cohort study using 100% of the Medicare claims for 516 392 patients undergoing pancreatic, esophageal, rectal, or lung resection for cancer between January 1, 2005, and December 31, 2016. Data were accessed between December 1, 2018, and April 30, 2019. Exposures High-risk cancer surgery in hospitals meeting and not meeting the minimum volume standards. Main Outcomes and Measures Patients having surgery in hospitals meeting the volume standard and 30-day and in-hospital mortality and complication rates. Results Overall, a total of 516 392 procedures (47 318 pancreatic resections, 29 812 esophageal resections, 116 383 rectal resections, and 322 879 lung resections) were included in the study, and patient mean (SD) age was 73.1 (7.5) years. Outcomes improved over time in both hospitals meeting and not meeting the minimum volume standards. Mortality after pancreatic resection decreased from 5.5% in 2005 to 4.8% in 2016 (P for trend <.001). Mortality after esophageal resection decreased from in 6.7% 2005 to 5.0% in 2016 (P for trend <.001). Mortality after rectal resection decreased from 3.6% in 2005 to 2.7 % in 2016 (P for trend <.001). Mortality after lung resection decreased from 4.2% in 2005 to 2.7 % in 2016 (P for trend <.001). Throughout the study period, there were no statistically significant differences in risk-adjusted mortality between hospitals meeting and not meeting the volume standards for esophageal, lung, and rectal cancer resections. Mortality rates after pancreatic resection were consistently lower at hospitals meeting the volume standard, although mortality at all hospitals decreased over the study period. For example, in 2016, risk-adjusted mortality rates for hospitals meeting the volume standard were 3.8% (95% CI, 3.3%-4.3%) compared with 5.7% (95% CI, 5.1%-6.5%) for hospitals that did not. Although an increasing majority of patients underwent surgery in hospitals meeting the Leapfrog volume standards over time, the overall proportion of hospitals meeting the standards in 2016 ranged from 5.6% for esophageal resection to 23.3% for pancreatic resection. Conclusions and Relevance Although volume remains an important factor for patient safety, the Leapfrog Group's minimum volume standards did not differentiate hospitals based on mortality for 3 of the 4 high-risk cancer operations assessed, and few hospitals were able to meet these standards. These findings highlight important tradeoffs between setting effective volume thresholds and practical expectations for hospital adherence and patient access to centers that meet those standards.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Karan R Chhabra
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Margaret E Smith
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Surgical Innovation Editor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| |
Collapse
|
19
|
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims. OBJECTIVE To assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n = 29 710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n = 25 941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates. EXPOSURES Dual eligibility for Medicare and Medicaid. MAIN OUTCOMES AND MEASURES Risk-adjusted all-cause 30-day readmission after surgery. RESULTS There were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12 879 of 25 724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25 724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12 578 of 24 333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24 333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, -1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates. CONCLUSIONS AND RELEVANCE This study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.
Collapse
Affiliation(s)
- Benjamin A. Y. Cher
- University of Michigan Medical School, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Andrew M. Ryan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Geoffrey J. Hoffman
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Systems, Population, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Kyle H. Sheetz
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
20
|
Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| |
Collapse
|
21
|
Affiliation(s)
| | - Kyle H. Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Andrew M. Ryan
- University of Michigan School of Public Health, Ann Arbor
| |
Collapse
|
22
|
Sheetz KH, Chhabra K, Nathan H, Dimick JB. The Quality of Surgical Care at Hospitals Associated With America's Highest-rated Medical Centers. Ann Surg 2020; 271:862-867. [DOI: 10.1097/sla.0000000000003195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
23
|
Chhabra KR, McGuire K, Sheetz KH, Scott JW, Nuliyalu U, Ryan AM. Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills. Health Aff (Millwood) 2020; 39:777-782. [PMID: 32293925 DOI: 10.1377/hlthaff.2019.01484] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
"Surprise" out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013-17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.
Collapse
Affiliation(s)
- Karan R Chhabra
- Karan R. Chhabra ( kchhabra@bwh. harvard. edu ) is a National Clinician Scholar at the Center for Healthcare Outcomes and Policy in the University of Michigan Institute for Healthcare Policy and Innovation, in Ann Arbor, and a house officer in the Department of Surgery at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Keegan McGuire
- Keegan McGuire is an MPH candidate in the School of Public Health, University of Michigan
| | - Kyle H Sheetz
- Kyle H. Sheetz is a house officer in the Department of Surgery, University of Michigan Medical School, in Ann Arbor
| | - John W Scott
- John W. Scott is an assistant professor in the Department of Surgery, University of Michigan Medical School
| | - Ushapoorna Nuliyalu
- Ushapoorna Nuliyalu is a statistician in the Center for Healthcare Outcomes and Policy, University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| |
Collapse
|
24
|
Sheetz KH, Nuliyalu U, Nathan H, Sonnenday CJ. Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing. JAMA Netw Open 2020; 3:e203850. [PMID: 32347950 PMCID: PMC7191322 DOI: 10.1001/jamanetworkopen.2020.3850] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice. OBJECTIVE To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. DESIGN, SETTING, AND PARTICIPANTS This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019. MAIN OUTCOMES AND MEASURES Thirty-day mortality and complications. RESULTS The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies. CONCLUSIONS AND RELEVANCE In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
Collapse
Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Usha Nuliyalu
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Christopher J. Sonnenday
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| |
Collapse
|
25
|
Vu JV, Sheetz KH, De Roo AC, Hiatt T, Hendren S. Variation in colectomy rates for benign polyp and colorectal cancer. Surg Endosc 2020; 35:802-808. [PMID: 32076864 DOI: 10.1007/s00464-020-07451-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp. METHODS We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race. RESULTS Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp. CONCLUSIONS The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.
Collapse
Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Ana C De Roo
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| | - Tadd Hiatt
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, 48103, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Ann Arbor, MI, 48109, USA
| |
Collapse
|
26
|
Abstract
Importance Hospitals are rapidly consolidating into regional delivery networks. To our knowledge, whether these multihospital networks leverage their combined assets to improve quality and provide a uniform standard of care has not been explored. Objective To evaluate the extent to which surgical outcomes varied across hospitals within the networks of the highest-rated US hospitals. Design, Settings, and Participants This longitudinal analysis of 87 hospitals that participated in 1 of 16 networks that are affiliated with US News & World Report Honor Roll hospitals used data from Medicare beneficiaries who were undergoing colectomy, coronary artery bypass graft, or hip replacement between 2005 and 2014 to evaluate the variation in risk-adjusted surgical outcomes at Honor Roll and affiliated hospitals within and across networks. The data were analyzed between April 20, 2018, and June 25, 2018. Main Outcomes and Measures Thirty-day postoperative complications, mortality, failure to rescue, and readmissions. Results Of 143 174 patients, 68 718 (48.0%) were men, 124 427 (86.9%) were white, and the mean (SD) age was 71.8 (9.9) years and 73.5 (9.1) years in Honor Roll and affiliated hospitals, respectively. Outcomes were not consistently better at Honor Roll hospitals compared with network affiliates. For example, Honor Roll hospitals had lower failure to rescue rates (13.3% vs 15.1%; odds ratio, 0.92; 95% CI, 0.86-0.98) but higher complication rates (22.1% vs 18.0%; odds ratio, 1.11; 95% CI, 1.03-1.19). Within networks, risk-adjusted outcomes varied widely across affiliated hospitals. The differences in failure to rescue varied by as little as 1.1-fold (range, 12.7%-14.3%) in some networks to as much as 4.9-fold (range, 7.6%-37.3%) in others. Similarly, complication rates varied by 1.1-fold (range, 21%-23%) to 4.3-fold (range, 6%-26%) across all networks. Conclusions and Relevance Surgical outcomes vary widely across hospitals affiliated with the US News & World Report Honor Roll hospitals. Public reporting mechanisms should provide patients with information on the quality of all network-affiliated hospitals. Networks should monitor variations in outcomes to characterize and improve the extent to which a uniform standard of care is being delivered.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.,Surgical Innovation Editor
| |
Collapse
|
27
|
Chhabra KR, Sheetz KH, Nuliyalu U, Dekhne MS, Ryan AM, Dimick JB. Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities. JAMA 2020; 323:538-547. [PMID: 32044941 PMCID: PMC7042888 DOI: 10.1001/jama.2019.21463] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. OBJECTIVE To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. EXPOSURE Patient, clinician, and insurance factors potentially related to out-of-network bills. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. RESULTS Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. CONCLUSIONS AND RELEVANCE In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.
Collapse
Affiliation(s)
- Karan R. Chhabra
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kyle H. Sheetz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | | | - Andrew M. Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
28
|
Abstract
IMPORTANCE Increasing use of robotic surgery for common surgical procedures with limited evidence and unclear clinical benefit is raising concern. Analyses of population-based trends in practice and how hospitals' acquisition of robotic surgical technologies is associated with their use are limited. OBJECTIVE To characterize trends in the use of robotic surgery for common surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This cohort study used clinical registry data from Michigan from January 1, 2012, through June 30, 2018. Trends were characterized in the use of robotic surgery for common procedures for which traditional laparoscopic minimally invasive surgery was already considered a safe and effective approach for most surgeons when clinically feasible. A multigroup interrupted time series analysis was performed to determine how procedural approaches (open, laparoscopic, and robotic) change after hospitals launch a robotic surgery program. Data were analyzed from March 1 through April 19, 2019. EXPOSURES Initiation of robotic surgery. MAIN OUTCOMES AND MEASURES Procedure approach (ie, robotic, open, or laparoscopic). RESULTS The study cohort included 169 404 patients (mean [SD] age, 55.4 [16.9] years; 90 595 women [53.5%]) at 73 hospitals. The use of robotic surgery increased from 1.8% in 2012 to 15.1% in 2018 (8.4-fold increase; slope, 2.1% per year; 95% CI, 1.9%-2.3%). For certain procedures, the magnitude of the increase was greater; for example, for inguinal hernia repair, the use of robotic surgery increased from 0.7% to 28.8% (41.1-fold change; slope, 5.4% per year; 95% CI, 5.1%-5.7%). The use of robotic surgery increased 8.8% in the first 4 years after hospitals began performing robotic surgery (2.8% per year; 95% CI, 2.7%-2.9%). This trend was associated with a decrease in laparoscopic surgery from 53.2% to 51.3% (difference, -1.9%; 95% CI, -2.2% to -1.6%). Before adopting robotic surgery, hospitals' use of laparoscopic surgery increased 1.3% per year. After adopting robotic surgery, the use of laparoscopic surgery declined 0.3% (difference in trends, -1.6%; 95% CI, -1.7% to -1.5%). CONCLUSIONS AND RELEVANCE These results suggest that robotic surgery has continued to diffuse across a broad range of common surgical procedures. Hospitals that launched robotic surgery programs had a broad and immediate increase in the use of robotic surgery, which was associated with a decrease in traditional laparoscopic minimally invasive surgery.
Collapse
Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor
| | - Jake Claflin
- currently a medical student at University of Michigan School of Medicine, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor
| |
Collapse
|
29
|
Sheetz KH, Nathan H. Methods for Enhancing Causal Inference in Observational Studies. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
30
|
Fry B, Sheetz KH. Being a Good Mentee in Outcomes Research. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
31
|
Sheetz KH, Ryan A. Accuracy of quality measurement for the Hospital Acquired Conditions Reduction Program. BMJ Qual Saf 2019; 29:605-607. [PMID: 31862774 DOI: 10.1136/bmjqs-2019-009747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Ryan
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
32
|
Sheetz KH, Dimick JB. Issues in the Adoption of Robotic Surgery-Reply. JAMA 2019; 322:1414-1415. [PMID: 31593267 DOI: 10.1001/jama.2019.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kyle H Sheetz
- Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| | - Justin B Dimick
- Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| |
Collapse
|
33
|
Sheetz KH, Nuliyalu U, Nathan H, Sonnenday CJ. Use of Comprehensive Practice Experience to Improve Surgeon-Specific Credentialing Standards. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
34
|
Sheetz KH, Woodside KJ, Shahinian VB, Dimick JB, Montgomery JR, Waits SA. Trends in Bariatric Surgery Procedures among Patients with ESKD in the United States. Clin J Am Soc Nephrol 2019; 14:1193-1199. [PMID: 31345840 PMCID: PMC6682821 DOI: 10.2215/cjn.01480219] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/20/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite the potential for improving health status or increasing access to transplantation, national practice patterns for bariatric surgery in obese patients with ESKD are poorly understood. The purpose of this study was to describe current trends in surgical care for this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using 100% Medicare data, we identified all beneficiaries undergoing bariatric surgery in the United States between 2006 and 2016. We evaluated longitudinal practice patterns using linear regression models. We also estimated risk-adjusted complications, readmissions, and length of stay using Poisson regression for patients with and without ESKD. RESULTS The number of patients with ESKD undergoing bariatric surgery increased ninefold between 2006 and 2016. The proportional use of sleeve gastrectomy increased from <1% in 2006 to 84% in 2016. For sleeve gastrectomy, complication rates were similar between patients with and without ESKD (3.4% versus 3.6%, respectively; difference, -0.3%; 95% confidence interval, -1.3% to 0.1%; P=0.57). However, patients with ESKD had more readmissions (8.6% versus 5.4%, respectively; difference, 3.2%; 95% confidence interval, 1.9% to 4.6%; P<0.001) and slightly longer hospitals stays (2.2 versus 1.9 days, respectively; difference, 0.3; 95% confidence interval, 0.1 to 0.4; P<0.001). CONCLUSIONS This study suggests that laparoscopic sleeve gastrectomy has replaced Roux-en-Y gastric bypass as the most common bariatric surgical procedure in patients with ESKD. The data also demonstrate a favorable complication profile in patients with sleeve gastrectomy.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, Section of Transplantation, .,The Center for Healthcare Outcomes and Policy, and
| | | | - Vahakn B Shahinian
- Division of Nephology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - John R Montgomery
- Department of Surgery, Section of Transplantation.,The Center for Healthcare Outcomes and Policy, and
| | - Seth A Waits
- Department of Surgery, Section of Transplantation.,The Center for Healthcare Outcomes and Policy, and
| |
Collapse
|
35
|
Abstract
PURPOSE Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. We evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. PATIENTS AND METHODS We merged data from the American Hospital Association's annual survey on hospital system affiliation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which systems centralized each procedure by calculating the annual proportion of surgeries performed at the highest-volume hospital within each system. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and readmissions after accounting for patient, hospital, and system characteristics. RESULTS The average degree of centralization varied from 25.2% (range, 6.6% to 100%) for colectomy to 71.2% (range, 8.3% to 100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.1% (95% CI, 0.8% to 1.4%) absolute reduction in 30-day mortality after pancreatectomy for each 20% increase in the degree of centralization within systems. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was two times higher in the least centralized systems than in the most centralized systems (8.9% v 3.7%, P < .01). Centralization was not associated with better outcomes for colectomy or proctectomy. CONCLUSION Greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these systems may also present unique opportunities to improve the quality of high-risk cancer care.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| |
Collapse
|
36
|
Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| |
Collapse
|
37
|
Tignanelli CJ, Sheetz KH, Petersen A, Park PK, Napolitano LM, Cooke CR, Cherry-Bukowiec JR. Utilization of Intensive Care Unit Nutrition Consultation Is Associated With Reduced Mortality. JPEN J Parenter Enteral Nutr 2019; 44:213-219. [PMID: 30900266 DOI: 10.1002/jpen.1534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/17/2019] [Accepted: 02/26/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes. METHODS Data from the Healthcare Cost and Utilization Project's state inpatient databases was utilized from 2010 - 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes. RESULTS Institutional ICU NC rates varied significantly (mean: 14%, range: 0.1%-73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%-25%). ICU patients who received NC had significantly lower in-hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48-0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53-0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38-0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4-2.3, P < 0.001). Patients who received follow-up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1-4.2, P < 0.001). CONCLUSIONS Rates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.
Collapse
Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley Petersen
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pauline K Park
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lena M Napolitano
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Colin R Cooke
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | |
Collapse
|
38
|
Sheetz KH, Waits SA. Common mistakes when using large databases for surgical research. Surgery 2019; 165:259-260. [DOI: 10.1016/j.surg.2018.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
|
39
|
Affiliation(s)
- Seth A Waits
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Kyle H Sheetz
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|
40
|
Claflin J, Dimick JB, Campbell DA, Englesbe MJ, Sheetz KH. Understanding Disparities in Surgical Outcomes for Medicaid Beneficiaries. World J Surg 2018; 43:981-987. [DOI: 10.1007/s00268-018-04891-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
41
|
|
42
|
Sheetz KH, Englesbe MJ. Rethinking performance benchmarks in kidney transplantation. Am J Transplant 2018; 18:2109-2110. [PMID: 29791069 DOI: 10.1111/ajt.14947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
43
|
Affiliation(s)
- Kyle H Sheetz
- From the Department of Surgery, University of Michigan, Ann Arbor, and the Department of Veterans Affairs, Washington, DC (K.H.S.); and the Ninth Secretary U.S. Department of Veterans Affairs (D.J.S.)
| | - David J Shulkin
- From the Department of Surgery, University of Michigan, Ann Arbor, and the Department of Veterans Affairs, Washington, DC (K.H.S.); and the Ninth Secretary U.S. Department of Veterans Affairs (D.J.S.)
| |
Collapse
|
44
|
Vu JV, Englesbe MJ, Sheetz KH. Invited commentary: databases for surgical health services research: collaborative quality improvement programs. Surgery 2018; 164:S0039-6060(17)30883-8. [PMID: 29398032 DOI: 10.1016/j.surg.2017.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI.
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Michigan Surgical Quality Collaborative (MSQC), Ann Arbor, MI
| |
Collapse
|
45
|
Sheetz KH, Norton EC, Regenbogen SE, Dimick JB. An Instrumental Variable Analysis Comparing Medicare Expenditures for Laparoscopic vs Open Colectomy. JAMA Surg 2017; 152:921-929. [PMID: 28614579 DOI: 10.1001/jamasurg.2017.1578] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Numerous study findings suggest that the use of laparoscopy is associated with lower health care costs for many operations, including colectomy. The extent to which these differences are due to the laparoscopic approach itself or selection bias from healthier patients undergoing the less invasive procedure is unclear. Objective To evaluate the differences in Medicare expenditures for laparoscopic and open colectomy. Design, Setting, and Participants A population-based study was conducted of Medicare beneficiaries undergoing laparoscopic or open colectomy between January 1, 2010, and December 31, 2012. The dates of the analysis were November 13 to December 10, 2016. Using instrumental variable methods to account for selection bias, actual Medicare payments after each procedure were evaluated. To identify the mechanisms of potential cost savings, the frequency and amount of physician, readmission, and postacute care payments were evaluated. Several sensitivity analyses were performed restricting the study population by patient demographic or surgeon specialty. Main Outcomes and Measures Actual Medicare expenditures up to 1 year after the index operation. Results The study population included 428 799 patients (mean [SD] age, 74 [10] years; 57.0% female). When using standard methods, patients undergoing laparoscopic colectomy (vs open) had lower total Medicare expenditures (mean, -$5547; 95% CI, -$5408 to -$5684; P < .01). When using instrumental variable methods, which account for potentially unmeasured patient characteristics, patients undergoing laparoscopic colectomy (vs open) still had lower Medicare expenditures (mean, -$3676; 95% CI, -$2444 to -$4907; P < .01), although the magnitude of the association was reduced. When examining the root causes of the difference in costs between patients who underwent laparoscopic and open colectomy, the key drivers were a reduction in costs from readmissions (mean, -$1102; 95% CI, -$1373 to -$831) and postacute care (mean, -$1446; 95% CI, -$1988 to -$935; P < .01). Conclusions and Relevance This population-based study demonstrates the influence of selection bias on cost estimates in comparative effectiveness research. While the use of laparoscopy reduced total episode payments, the source of savings is in the postacute care period, not the index hospitalization.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
| | - Edward C Norton
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor.,Department of Economics, University of Michigan, Ann Arbor.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Surgical Innovation Editor
| |
Collapse
|
46
|
Varban OA, Sheetz KH, Cassidy RB, Stricklen A, Carlin AM, Dimick JB, Finks JF. Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Surg Obes Relat Dis 2016; 13:560-567. [PMID: 28089439 DOI: 10.1016/j.soard.2016.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/10/2016] [Accepted: 11/29/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG). BACKGROUND Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood. METHODS We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10. RESULTS Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate<1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line. CONCLUSION Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.
Collapse
Affiliation(s)
- Oliver A Varban
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Ruth B Cassidy
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Amanda Stricklen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Arthur M Carlin
- Wayne State University, Detroit, Michigan; Department of Surgery, Henry Ford Health System, Dearborn, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| |
Collapse
|
47
|
Sheetz KH, Dimick JB. Minimally invasive operative techniques: Is less always more? Surgery 2016; 161:1455-1457. [PMID: 27913037 DOI: 10.1016/j.surg.2016.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Kyle H Sheetz
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
48
|
Sheetz KH, Derstine B, Englesbe MJ. Propensity scores for comparative effectiveness research: Finding the right match. Surgery 2016; 160:1425-1426. [DOI: 10.1016/j.surg.2016.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/30/2016] [Indexed: 11/26/2022]
|
49
|
Abstract
OBJECTIVE To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy. DATA SOURCES National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy. STUDY DESIGN Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy. PRINCIPAL FINDINGS Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy. CONCLUSIONS This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
Collapse
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| |
Collapse
|
50
|
Varban OA, Cassidy RB, Sheetz KH, Cain-Nielsen A, Carlin AM, Schram JL, Weiner MJ, Bacal D, Stricklen A, Finks JF. Technique or technology? Evaluating leaks after gastric bypass. Surg Obes Relat Dis 2016; 12:264-72. [DOI: 10.1016/j.soard.2015.07.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 07/16/2015] [Accepted: 07/18/2015] [Indexed: 01/19/2023]
|