Risk-adjusted 30-day Mortality Research Articles

Trends in Transcatheter Aortic Valve Replacement Outcomes

Although transcatheter aortic valve replacement (TAVR) outcomes in the US have improved substantially since 2011, it is unknown whether these trends have continued since 2019. To examine changes in risk-adjusted TAVR outcomes from 2019 to 2022 and to examine any noteworthy trends over time. This cohort study examined data from patients with severe aortic stenosis treated with TAVR at 786 US hospitals between January 1, 2019, and March 31, 2022, included in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapies (TVT) Registry. Patients who underwent TAVR. The primary outcome was 30-day mortality, and the secondary outcomes were in-hospital mortality and 30-day composite adverse events. To understand factors explaining these trends, a series of logistic regression models was constructed for each outcome, with time as the primary explanatory variable. After adjusting for changing patent characteristics and procedural factors, a series of exploratory analyses was performed to examine the extent to which these findings could be explained by several plausible hypotheses. This study's analytic cohort included a total of 210 495 patients. Median (IQR) patient age was 79 (73-85) years, and 91 313 patients (43.4%) were female. Median (IQR) STS predicted risk of mortality (PROM) was 3.3% (2.0%-5.3%). There were no significant changes in unadjusted 30-day mortality from quarter 1 of 2019 (2.4%) to the end of quarter 1 of 2022 (2.2%) (P for trend = .10), with an unadjusted odds ratio (OR) for time of 0.98 per year (95% CI, 0.94-1.01). After adjusting for patient characteristics, the OR increased to 1.05 per year (95% CI, 1.02-1.08), which increased further after adjusting for procedural characteristics to 1.09 per year (95% CI, 1.05-1.13). In exploratory analyses, there were no meaningful changes in the adjusted odds of death after excluding sites that entered the STS/ACC TVT Registry in 2019 or later (OR, 1.09; 95% CI, 1.05-1.13), low-volume sites (OR, 1.09; 95% CI, 1.06-1.13), low-risk patients (OR, 1.11; 95% CI, 1.07-1.15), patients with a bicuspid aortic valve (OR, 1.09; 95% CI, 1.05-1.13), in-hospital deaths (OR, 1.08; 95% CI, 1.03-1.14), or patients who experienced a major vascular complication (OR, 1.09; 95% CI, 1.05-1.12). In this observational cohort study performing a national analysis of outcomes after TAVR, it was found that risk-adjusted 30-day mortality increased modestly from January 2019 to March 2022. However, no site-level, patient-related, or process-related factors were identified that could explain these findings. Although the absolute increase in risk-adjusted mortality during the study period was relatively small, these findings warrant continued surveillance.

Variation in acute cholecystitis outcomes and processes of care in patients with cancer

BackgroundPatients undergoing active cancer therapy or with metastatic cancer are at increased risk for acute cholecystitis and often present to general surgeons for evaluation and management. There is a paucity of data regarding the treatment processes used in these patients and the clinical outcomes achieved. Optimal management of acute cholecystitis in patients with cancer requires understanding their unique risk profile and options for treatment. MethodsEmergency general surgery data were collected at 10 hospitals from July 1, 2019, to February 29, 2024. Patients presenting with acute cholecystitis were selected for analysis. Propensity score matching was used to create matched cohorts of patients by the presence or absence of an active malignancy. The primary outcome was 30-day mortality. Secondary outcomes included complications, length of stay, readmission, and discharge disposition. Processes investigated include treatment modality, time to operation, and surgical technique. ResultsThe analysis included 8,673 patients. Mean age was 53.2 ± 19 years, 61.4% were female, and 17.8% were non-White. In total, 3.3% of patients had an active malignancy. Risk-adjusted 30-day mortality was higher in the cancer cohort (odds ratio: 5.85, 95% confidence interval: 2.38–14.4, P < .001). Patients with cancer also had higher rates of infectious complications (odds ratio: 2.55, 95% confidence interval: 1.54–4.2, P < .001), including sepsis (odds ratio: 2.95, 95% confidence interval: 1.61–5.39, P < .001) and pneumonia (odds ratio: 6.67, 95% confidence interval: 1.75–25.3, P < .005). Patients with cancer were more likely to receive nonoperative management (odds ratio: 2.85, 95% confidence interval: 2.11–3.84, P < .001). ConclusionPatients with cancer presenting with acute cholecystitis experience worse clinical outcomes after controlling for other factors. Furthermore, there is variation in the treatment process with increased rates of nonoperative management. These results have implications for the management of this population, particularly in relation to the impact on concurrent oncologic treatment plans.

Interhospital variability of risk-adjusted mortality rates and associated structural factors in patients undergoing emergency laparotomy: England and Wales population-level analysis.

Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors. A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles. Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004). This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes. Original Research Article; Level II.

Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery.

The National Accreditation Program for Rectal Cancer (NAPRC) defined a set of standards in 2017 centered on multidisciplinary program structure, evidence-based care processes, and internal audit to address widely variable rectal cancer practices and outcomes across US hospitals. There have been no studies to-date testing the association between NAPRC accreditation and rectal cancer outcomes. This was a retrospective, observational study of Medicare beneficiaries aged 65 to 99 years with rectal cancer who underwent proctectomy from 2017 to 2020. The primary exposure was NAPRC accreditation and the primary outcomes included mortality (in-hospital, 30 day, and 1 year) and 30-day complications, readmissions, and reoperations. Associations between NAPRC accreditation and each outcome were tested using multivariable logistic regression with risk-adjustment for patient and hospital characteristics. Among 1,985 hospitals, 65 were NAPRC-accredited (3.3%). Accredited hospitals were more likely to be nonprofit and teaching with 250 or more beds. Among 20,202 patients, 2,078 patients (10%) underwent proctectomy at an accredited hospital. Patients at accredited hospitals were more likely to have an elective procedure with a minimally invasive approach and sphincter preservation. Risk-adjusted in-hospital mortality (1.1% vs 1.3%; p = 0.002), 30-day mortality (2.1% vs 2.9%; p < 0.001), 30-day complication (18.3% vs 19.4%; p = 0.01), and 1-year mortality rates (11% vs 12.1%; p < 0.001) were significantly lower at accredited compared with nonaccredited hospitals. NAPRC-accredited hospitals have lower risk-adjusted morbidity and mortality for major rectal cancer surgery. Although NAPRC standards address variability in practice, without directly addressing surgical safety, our findings suggest that NAPRC-accredited hospitals may provide higher quality surgical care.

Development and Validation of the Hospital Medicine Safety Sepsis Initiative Mortality Model

When comparing outcomes after sepsis, it is essential to account for patient case mix to make fair comparisons. We developed a model to assess risk-adjusted 30-day mortality in the Michigan Hospital Medicine Safety sepsis initiative (HMS-Sepsis). Can HMS-Sepsis registry data adequately predict risk of 30-day mortality? Do performance assessments using adjusted vsunadjusted data differ? Retrospective cohort of community-onset sepsis hospitalizations in the HMS-Sepsis registry (April 2022-September 2023), with split-derivation (70%) and validation (30%) cohorts. We fit a risk-adjustment model (HMS-Sepsis mortality model) incorporating acute physiologic, demographic, and baseline health data and assessed model performance using concordance (C) statistics, Brier's scores, and comparisons of predicted vsobserved mortality by deciles of risk. We compared hospital performance (first quintile, middle quintiles, fifth quintile) using observed vsadjusted mortality to understand the extent to which risk adjustment impacted hospital performance assessment. Among 17,514 hospitalizations from 66 hospitals during the study period, 12,260 hospitalizations (70%) were used for model derivation and 5,254 hospitalizations (30%) were used for model validation. Thirty-day mortality for the total cohort was 19.4%. The final model included 13 physiologic variables, two physiologic interactions, and 16 demographic and chronic health variables. The most significant variables were age, metastatic solid tumor, temperature, altered mental status, and platelet count. The model C statistic was 0.82 for the derivation cohort, 0.81 for the validation cohort, and≥ 0.78 for all subgroups assessed. Overall calibration error was 0.0%, and mean calibration error across deciles of risk was 1.5%. Standardized mortality ratios yielded different assessments than observed mortality for 33.9%of hospitals. The HMS-Sepsis mortality model showed strong discrimination and adequate calibration and reclassified one-third of hospitals to a different performance category from unadjusted mortality. Based on its strong performance, the HMS-Sepsis mortality model can aid in fair hospital benchmarking, assessment of temporal changes, and observational causal inference analysis.

Sex Disparities After Coronary Artery Bypass Grafting and Hospital Quality

Concern has been raised about persistent sex disparities after coronary artery bypass grafting, with female patients having higher mortality. However, whether these disparities persist across hospitals of different qualities is unknown. To evaluate sex disparities in 30-day mortality after coronary artery bypass grafting across high- and low-quality hospitals. This cross-sectional, retrospective cohort study evaluated Medicare beneficiaries undergoing coronary artery bypass grafting between October 1, 2015, and March 31, 2020. Data analysis was performed from July 1, 2023, to December 1, 2023. The primary exposures were hospital quality and sex. For hospital quality, hospitals were placed into rank order by their overall risk-adjusted mortality rate and divided into quintiles. Risk-adjusted 30-day mortality using a logistic regression model accounting for patient factors, including sex, age, comorbidities, elective vs unplanned admission, number of bypass grafts, use of arterial graft, and year of surgery. A total of 444 855 beneficiaries (mean [SD] age, 71.5 [7.5] years; 120 333 [27.1%] female and 324 522 [72.9%] male) were studied. Compared with male beneficiaries, female beneficiaries were more likely to have an unplanned admission (66 425 [55.2%] vs 157 895 [48.7%], P < .001) and receive care at low-quality (vs high-quality) hospitals (odds ratio, 1.26; 95% CI, 1.23-1.29; P < .001). Overall, risk-adjusted female mortality was 4.24% (95% CI, 4.20%-4.27%), and male mortality was 2.75% (95% CI, 2.75%-2.77%), with an absolute difference of 1.48 (95% CI, 1.45-1.51) percentage points (P < .001). At the highest-quality hospitals, male mortality was 1.57% (95% CI, 1.56%-1.59%), and female mortality was 2.58% (95% CI, 2.54%-2.62%), with an absolute difference of 1.01 (95% CI, 0.97-1.04) percentage points (P < .001). At the lowest-quality hospitals, male mortality was 4.94% (95% CI, 4.88%-5.01%), and female mortality was 7.02% (95% CI, 6.90%-7.13%), with an absolute difference of 2.07 (95% CI, 1.95-2.19) percentage points (P < .001). Female beneficiaries receiving care at low-quality hospitals had a higher mortality than male beneficiaries receiving care at the high-quality hospitals (7.02% vs 1.57%, P < .001). In this cohort study of Medicare beneficiaries undergoing coronary artery bypass grafting, female beneficiaries were more likely to receive care at low-quality hospitals, where the sex disparity in mortality was double that of high-quality hospitals. Quality improvement targeting low-quality hospitals as well as equitable referral of female beneficiaries to higher-quality hospitals may narrow the sex disparity after coronary artery bypass grafting.

Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019.

Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.

Missed opportunities in hospital quality measurement during the COVID-19 pandemic: a retrospective investigation of US hospitals’ CMS Star Ratings and 30-day mortality during the early pandemic

ObjectivesIn the USA and UK, pandemic-era outcome data have been excluded from hospital rankings and pay-for-performance programmes. We assessed the relationship between US hospitals’ pre-pandemic Centers for Medicare and Medicaid...

Temporal Trend in Revascularization for Patients With Ischemic Cardiomyopathy and Multivessel Coronary Artery Disease.

Current guidelines recommend revascularization in patients with ischemic cardiomyopathy (ICM). However, there is limited information about the trends and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in ischemic cardiomyopathy patients with multivessel coronary artery disease. Using New Jersey state mandatory registries, 8083 patients with ischemic cardiomyopathy with CABG or PCI revascularization for multivessel coronary artery disease from 2007 to 2018 were included in the analysis. Joinpoint regression and multivariable logistic regression analyses were performed to assess the annual percentage change in trends and predictors of the 30-day mortality rate, respectively. A decline in CABG procedures was observed from 2007 to 2011 (annual percentage change, -11.5%; P=0.003), followed by stabilization. The PCI trend remained unchanged from 2007 to 2010 and then increased significantly (annual percentage change, 3.2%; P=0.02). In the subsample of patients with proximal left anterior descending artery plus circumflex and right coronary artery, CABG was a predominant procedure until 2011, and the proportion of both procedures did not differ thereafter. In the subsample of patients with left anterior descending artery and any other artery stenosis, PCI remained dominant from 2007 to 2018, while in patients with left main and any other artery stenosis, CABG remained dominant from 2007 to 2018 (P<0.001). The 30-day risk-adjusted mortality rate was higher after PCI versus CABG for each year, but after adjustment for completeness of revascularization, there was no difference between groups. The patterns of revascularization procedures for patients with ischemic cardiomyopathy with multivessel coronary artery disease have changed over the years, as evidenced by the changes in CABG and PCI trends. CABG and PCI had comparable 30-day risk-adjusted mortality risks.

Bundled Payments for Care Improvement and Quality of Care and Outcomes in Heart Failure

The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare. To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program. This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023. Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price. Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate. During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94 530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30 723 patients, 29.8%) were 75 years or younger; 54 629 (52.9%) were female, and 48 622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based β-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate. In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.

Risk-Adjusted Cumulative Sum for Early Detection of Hospitals With Excess Perioperative Mortality

National surgical quality improvement programs lack tools for early detection of quality or safety concerns, which risks patient safety because of delayed recognition of poor performance. To compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. National, observational, hospital-level, comparative effectiveness study of 697 566 patients. Identification of hospitals with excess, risk-adjusted, quarterly 30-day mortality using observed to expected ratios (ie, current criterion standard in the Veterans Affairs Surgical Quality Improvement Program) was compared with the risk-adjusted CUSUM. Patients included in the study underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. Number of hospitals identified as having excess risk-adjusted 30-day mortality. The cohort included 697 566 patients treated at 104 hospitals across 24 quarters. The mean (SD) age was 60.9 (13.2) years, 91.4% were male, and 8.6% were female. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters), respectively. During 2496 total quarters of data, outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]; trend test, P < .001). Of 274 hospital quarters detected with observed to expected ratios, 72.6% (199) were concurrently detected by at least 1 CUSUM signal vs 42.7% (117) by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49; trend test, P < .001). This study found that with CUSUM, hospitals with excess perioperative mortality can be identified well in advance of standard end-of-quarter reporting, which suggests episodic evaluation strategies fail to detect out-of-control processes and place patients at risk. Continuous performance evaluation tools should be adopted in national quality improvement programs to prevent avoidable patient harm.

Association of persistent poverty and U.S. News and World Report hospital rankings among patients undergoing major surgery

BackgroundWe sought to determine the association of persistent poverty on patient outcomes relative to US News World Report (USNWR) rankings among individuals undergoing common major surgical procedures. MethodsMedicare beneficiaries who underwent AAA repair, CABG, colectomy, or lung resection were identified. Multivariable logistic regression was used to evaluate the relationship between care at USNWR hospitals, county-level duration of poverty (never-high poverty (NHP); intermittent high poverty (IHP): persistent-poverty (PP)) and 30-day mortality. ResultsAmong 916,164 beneficiaries, individuals residing in PP neighborhoods who received surgical care at ranked hospitals had lower risk-adjusted 30-day mortality (5.89% vs 8.89%; p ​< ​0.001). On multivariable analysis, 30-day mortality was lower at ranked hospitals across all poverty categories with greatest decrease among patients from PP regions (NHP: OR-0.91, 95%CI0.87–0.95; IHP: OR-0.78, 95%CI0.69–0.88; PP: OR-0.69, 95%CI0.57–0.83; p ​< ​0.001). ConclusionReceipt of surgical care at top-ranked hospitals was associated with improvement in postoperative mortality, especially among patients residing in persistent poverty..

Benchmarking Outcomes of Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valves

BackgroundThe relative roles for transcatheter and surgical aortic valve replacement (SAVR) for bicuspid aortic valve (AV) stenosis are debated. This study analyzes the 5-year longitudinal outcomes of isolated SAVR in bicuspid vs tricuspid AV patients, particularly in low-risk patients. MethodsAll patients undergoing isolated index SAVR at 1146 United States hospitals in The Society of Thoracic Surgeons (STS) Adult Cardiac database between July 1, 2011, and December 31, 2018, with linkage to Medicare claims, were analyzed. ResultsA total of 65,687 patients were analyzed, including of 9131 bicuspid patients (13.9%). Compared with tricuspid patients, bicuspid patients were significantly younger (median 70 vs 74 years, P < .001) with lower Society of Thoracic Surgeons predicted risk of mortality scores (mean 1.6% vs 2.3%, P < .001) and lower risk profile. Risk-adjusted 30-day mortality and major morbidity were similar, but risk-adjusted 5-year mortality was significantly lower in the bicuspid patients (adjusted hazard ratio, 0.72; 95% CI, 0.66-0.77), specifically in low-risk patients (adjusted hazard ratio, 0.69; 95% CI, 0.64-0.76). Additionally, the bicuspid cohort had a lower 5-year readmission risk of heart failure, stroke, bleeding, or other cardiovascular causes (all P < .05). ConclusionsIn this nationally representative study, 30-day mortality was similar, but risk-adjusted 5-year mortality was significantly lower in bicuspid patients undergoing isolated SAVR compared with tricuspid patients, specifically low-risk and normal left ventricular ejection fraction patients. This analysis provides a much-needed 5-year longitudinal national-level benchmark to better inform the discussion of transcatheter vs SAVR in bicuspid patients.

Outcomes Among Patients Hospitalized With Non–COVID-19 Conditions Before and During the COVID-19 Pandemic in Alberta and Ontario, Canada

The association of inpatient COVID-19 caseloads with outcomes in patients hospitalized with non-COVID-19 conditions is unclear. To determine whether 30-day mortality and length of stay (LOS) for patients hospitalized with non-COVID-19 medical conditions differed (1) before and during the pandemic and (2) across COVID-19 caseloads. This retrospective cohort study compared patient hospitalizations between April 1, 2018, and September 30, 2019 (prepandemic), vs between April 1, 2020, and September 30, 2021 (during the pandemic), in 235 acute care hospitals in Alberta and Ontario, Canada. All adults hospitalized for heart failure (HF), chronic obstructive pulmonary disease (COPD) or asthma, urinary tract infection or urosepsis, acute coronary syndrome, or stroke were included. The monthly surge index for each hospital from April 2020 through September 2021 was used as a measure of COVID-19 caseload relative to baseline bed capacity. The primary study outcome was 30-day all-cause mortality after hospital admission for the 5 selected conditions or COVID-19 as measured by hierarchical multivariable regression models. Length of stay was the secondary outcome. Between April 2018 and September 2019, 132 240 patients (mean [SD] age, 71.8 [14.8] years; 61 493 female [46.5%] and 70 747 male [53.5%]) were hospitalized for the selected medical conditions as their most responsible diagnosis compared with 115 225 (mean [SD] age, 71.9 [14.7] years, 52 058 female [45.2%] and 63 167 male [54.8%]) between April 2020 and September 2021 (114 414 [99.3%] of whom had negative SARS-CoV-2 test results). Patients admitted during the pandemic with any of the selected conditions and concomitant SARS-CoV-2 infection exhibited a much longer LOS (mean [SD], 8.6 [7.1] days or a median of 6 days longer [range, 1-22 days]) and greater mortality (varying across diagnoses, but with a mean [SD] absolute increase at 30 days of 4.7% [3.1%]) than those without coinfection. Patients hospitalized with any of the selected conditions without concomitant SARS-CoV-2 infection had similar LOSs during the pandemic as before the pandemic, and only patients with HF (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.24) and COPD or asthma (AOR, 1.41; 95% CI, 1.30-1.53) had a higher risk-adjusted 30-day mortality during the pandemic. As hospitals experienced COVID-19 surges, LOS and risk-adjusted mortality remained stable for patients with the selected conditions but were higher in patients with COVID-19. Once capacity reached above the 99th percentile, patients' 30-day mortality AOR was 1.80 (95% CI, 1.24-2.61) vs when the surge index was below the 75th percentile. This cohort study found that during surges in COVID-19 caseloads, mortality rates were significantly higher only for hospitalized patients with COVID-19. However, most patients hospitalized with non-COVID-19 conditions and negative SARS-CoV-2 test results (except those with HF or with COPD or asthma) exhibited similar risk-adjusted outcomes during the pandemic as before the pandemic, even during COVID-19 caseload surges, suggesting resiliency in the event of regional or hospital-specific occupancy strains.

Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock

Recent studies have produced inconsistent findings regarding the outcomes of the percutaneous microaxial left ventricular assist device (LVAD) during acute myocardial infarction with cardiogenic shock (AMICS). To compare the percutaneous microaxial LVAD vs alternative treatments among patients presenting with AMICS using observational analyses of administrative data. This comparative effectiveness research study used Medicare fee-for-service claims of patients admitted with AMICS undergoing percutaneous coronary intervention from October 1, 2015, through December 31, 2019. Treatment strategies were compared using (1) inverse probability of treatment weighting to estimate the effect of different baseline treatments in the overall population; (2) instrumental variable analysis to determine the effectiveness of the percutaneous microaxial LVAD among patients whose treatment was influenced by cross-sectional institutional practice patterns; (3) an instrumented difference-in-differences analysis to determine the effectiveness of treatment among patients whose treatment was influenced by longitudinal changes in institutional practice patterns; and (4) a grace period approach to determine the effectiveness of initiating the percutaneous microaxial LVAD within 2 days of percutaneous coronary intervention. Analysis took place between March 2021 and December 2022. Percutaneous microaxial LVAD vs alternative treatments (including medical therapy and intra-aortic balloon pump). Thirty-day all-cause mortality and readmissions. Of 23 478 patients, 14 264 (60.8%) were male and the mean (SD) age was 73.9 (9.8) years. In the inverse probability of treatment weighting analysis and grace period approaches, treatment with percutaneous microaxial LVAD was associated with a higher risk-adjusted 30-day mortality (risk difference, 14.9%; 95% CI, 12.9%-17.0%). However, patients receiving the percutaneous microaxial LVAD had a higher frequency of factors associated with severe illness, suggesting possible confounding by measures of illness severity not available in the data. In the instrumental variable analysis, 30-day mortality was also higher with percutaneous microaxial LVAD, but patient and hospital characteristics differed across levels of the instrumental variable, suggesting possible confounding by unmeasured variables (risk difference, 13.5%; 95% CI, 3.9%-23.2%). In the instrumented difference-in-differences analysis, the association between the percutaneous microaxial LVAD and mortality was imprecise, and differences in trends in characteristics between hospitals with different percutaneous microaxial LVAD use suggested potential assumption violations. In observational analyses comparing the percutaneous microaxial LVAD to alternative treatments among patients with AMICS, the percutaneous microaxial LVAD was associated with worse outcomes in some analyses, while in other analyses, the association was too imprecise to draw meaningful conclusions. However, the distribution of patient and institutional characteristics between treatment groups or groups defined by institutional differences in treatment use, including changes in use over time, combined with clinical knowledge of illness severity factors not captured in the data, suggested violations of key assumptions that are needed for valid causal inference with different observational analyses. Randomized clinical trials of mechanical support devices will allow valid comparisons across candidate treatment strategies and help resolve ongoing controversies.

Mortality Among US Veterans Admitted to Community vs Veterans Health Administration Hospitals for COVID-19

Veterans Health Administration (VHA) enrollees receive care for COVID-19 in both VHA and non-VHA (ie, community) hospitals, but little is known about the frequency or outcomes of care for veterans with COVID-19 in VHA vs community hospitals. To compare outcomes among veterans admitted for COVID-19 in VHA vs community hospitals. This retrospective cohort study used VHA and Medicare data from March 1, 2020, to December 31, 2021, on hospitalizations for COVID-19 in 121 VHA and 4369 community hospitals in the US among a national cohort of veterans (aged ≥65 years) enrolled in both the VHA and Medicare with VHA care in the year prior to hospitalization for COVID-19 based on the primary diagnosis code. Admission to VHA vs community hospitals. The main outcomes were 30-day mortality and 30-day readmission. Inverse probability of treatment weighting was used to balance observable patient characteristics (eg, demographic characteristics, comorbidity, mechanical ventilation on admission, area-level social vulnerability, distance to VHA vs community hospitals, and date of admission) between VHA and community hospitals. The cohort included 64 856 veterans (mean [SD] age, 77.6 [8.0] years; 63 562 men [98.0%]) dually enrolled in the VHA and Medicare who were hospitalized for COVID-19. Most (47 821 [73.7%]) were admitted to community hospitals (36 362 [56.1%] admitted to community hospitals via Medicare, 11 459 [17.7%] admitted to community hospitals reimbursed via VHA's Care in the Community program, and 17 035 [26.3%] admitted to VHA hospitals). Admission to community hospitals was associated with higher unadjusted and risk-adjusted 30-day mortality compared with admission to VHA hospitals (crude mortality, 12 951 of 47 821 [27.1%] vs 3021 of 17 035 [17.7%]; P < .001; risk-adjusted odds ratio, 1.37 [95% CI, 1.21-1.55]; P < .001). Readmission within 30 days was less common after admission to community compared with VHA hospitals (4898 of 38 576 [12.7%] vs 2006 of 14 357 [14.0%]; risk-adjusted hazard ratio, 0.89 [95% CI, 0.86-0.92]; P < .001). This study found that most hospitalizations for COVID-19 among VHA enrollees aged 65 years or older were in community hospitals and that veterans experienced higher mortality in community hospitals than in VHA hospitals. The VHA must understand the sources of the mortality difference to plan care for VHA enrollees during future COVID-19 surges and the next pandemic.

Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study

BackgroundNational quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres. MethodsAll patients in the Norwegian Trauma Registry in 2015–2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied. Results28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P<0.0001), amongst severely injured patients in the Northern health region (4.80 fewer excess survivors per 100 patients, P = 0.004), and in hospitals with <100 trauma admissions per year (0.65 fewer excess survivors than in hospitals with ≥100 admissions, P = 0.01). However, the only statistically significant effects in a multivariable logistic case mix-adjusted descriptive model were hospital level and health region. Case-mix adjusted odds ratio for survival for severely injured patients directly admitted to a trauma centre vs. an acute care hospital was 2.04 (95% CI 1.04–4.00, P = 0.04), and if admitted in the Northern health region vs. all other health regions was 0.47 (95% CI 0.27–0.84, P = 0.01). The proportion of cases admitted directly to the regional trauma centre in the sparsely populated Northern health region was half of that in the other regions (18.4% vs. 37.6%, P<0.0001). ConclusionDifferences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas.

Hospital- and Patient-Level Analysis of Quality Indicators in Acute Coronary Syndrome Care: A Nationwide Database Study.

This study aimed to clarify the variations in the quality of care provided to patients with acute coronary syndrome (ACS) and to investigate the association between quality of care and mortality at both hospital and patient levels with the use of a nationwide database. Patients with ACS who underwent percutaneous coronary intervention (PCI) from April 2014 to March 2018 were included from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Twelve quality indicators (QIs) available from administrative data and the association of the QIs with all-cause mortality were investigated. From the analysis of 216,436 patients from 1215 hospitals, adherence to PCI on admission day, aspirin use on arrival, P2Y12 inhibitor use, and left ventricular function assessment were high (median proportion > 90%), and adherence to outpatient cardiac rehabilitation was low (median proportion < 10%). At the hospital level, acute-phase composite QI score was associated with reduced risk-adjusted 30-day mortality (β=-0.92 [95% confidence interval-1.19 to-0.65]; P < 0.001). At the patient level, all acute-phase and subacute-phase QIs were inversely associated with 30-day and 2-year mortalities, respectively (all P < 0.001). Substantial variations in ACS care were observed in the current nationwide database. High adherence to the QI sets was associated with significant survival gains at both hospital and patient levels. Multilevel approach in QI assessment may be effective for improvement of survival in this population.

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings.

Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. Cross-sectional. Population-based. Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. Laura and John Arnold Foundation.