Risk-adjusted 30-day Mortality Research Articles

Survival Benefit With Concomitant Clopidogrel and Glycoprotein IIb/IIIa Inhibitor Therapy at Ad Hoc Percutaneous Coronary Intervention

To study clinical outcomes in patients given glycoprotein (GP) IIb/IIIa inhibitors with concomitant clopidogrel at the time of ad hoc percutaneous coronary interventions (PCI). We studied 30-day and long-term outcomes of patients undergoing elective or urgent PCI from March 1, 1998, to December 31, 2006, stratified by administration of GP IIb/IIIa inhibitors with concomitant clopidogrel treatment at the time of ad hoc PCI. The mean+/-SD age was 66.3+/-11.9 years in 5196 patients receiving compared with 67.8+/-11.8 years in 4681 patients not receiving a GP IIb/IIIa inhibitor (P<.001). Overall, 30-day unadjusted mortality was lower in patients who received a GP IIb/IIIa inhibitor (1.0% vs 1.2%; P=.22). Long-term mortality was significantly lower (P<.001) in patients receiving GP IIb/IIIa inhibitors at the time of PCI. After propensity analysis to adjust for the likelihood of receiving GP IIb/IIIa inhibitors on the basis of clinical, angiographic, and procedural characteristics, a significant reduction in 30-day mortality with GP IIb/IIIa inhibitor use was identified (hazard ratio, 0.56; 95% confidence interval, 0.36-0.87; P=.01). Kaplan-Meier analysis (median follow-up, 48 months) revealed a significant improvement in long-term survival in patients receiving a GP IIb/IIIa inhibitor at the time of ad hoc PCI that persisted after propensity adjustments (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98; P=.021). Patients treated with drug-eluting stents showed a significant improvement in adjusted long-term mortality. In patients undergoing elective or urgent ad hoc PCI, coadministration of a GP IIb/IIIa inhibitor and dual antiplatelet therapy is associated with reduced risk-adjusted 30-day and long-term mortality.

EVALUATION OF SURGICAL PERFORMANCE USING V‐POSSUM RISK‐ADJUSTED MORTALITY RATES

Vascular-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (V-POSSUM) is a risk-adjusted scoring system for predicting 30-day mortality in patients undergoing vascular surgery. It can assess surgical performance by comparing predicted deaths with observed deaths. The aim of this analysis was to assess trends in surgical performance over time using risk-adjusted 30-day mortality as the primary outcome. Major vascular surgery procedures (n = 454) were prospectively scored for V-POSSUM between 1995 and 2006. Procedures were divided into 11 consecutive time bands. Observed and predicted deaths were compared using the logistic regression equation derived for V-POSSUM. The observed death rates decreased over time, as did the predicted number of deaths calculated from the V-POSSUM scores. The overall predicted mortality rate was 17.2% and the rate varied with the 12-month period, with a high of 23.9% and a low of 9.2%. The downward trend in the predicted rate shows that the patient risk factors have changed over time and that the risk of dying has declined by almost 50% (from 21.6 to 11.1%). There was a trend towards improved surgical performance over time, with a drop in the observed to predicted ratios of deaths. Observed and predicted deaths changed over the study periods. There was a trend towards improved performance compared with the risk-adjusted predicted mortality. V-POSSUM is a useful tool in the longitudinal assessment of performance in major vascular surgery.

Mortality After Nonemergent Major Surgery Performed on Friday Versus Monday Through Wednesday

To determine whether nonemergent major surgery leads to higher mortality when performed on Friday versus early weekdays. Adults admitted emergently to acute-care hospitals on weekends experience higher mortality than those admitted on weekdays. Cohort study of 188,212 patients undergoing nonemergent major surgery at 124 Veterans Affairs hospitals from 2000 to 2004. Risk-adjusted 30-day mortality was compared for operations performed on Fridays versus Mondays through Wednesdays. Data were derived from the Veterans Affairs' National Surgical Quality Improvement Program database. Patients were divided into 3 groups: floor (admitted postoperatively to regular floor), ICU (admitted postoperatively to intensive care unit), and outpatient (not admitted postoperatively). A stepwise logistic regression analysis was used to test the effect of day of surgery (Friday vs. Monday-through-Wednesday) on 30-day mortality in the presence of characteristics that were significant in bivariate analysis. In the floor group (n = 89,786), operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays (2.94% vs. 2.18%; odds ratio, 1.36; 95% confidence interval, 1.24-1.49; P < 0.001). After adjusting for patient characteristics, odds ratio of 30-day mortality for operations on Fridays, when compared with Mondays through Wednesdays, was 1.17 (95% confidence interval, 1.05-1.26; P = 0.003). Within the ICU (n = 14,271) and outpatient (n = 84,155) groups, nonsignificant differences in 30-day mortality were observed for operations on Fridays versus Mondays through Wednesdays. For patients admitted to regular hospital floors after nonemergent major surgery, mortality is increased if surgery is performed on Friday versus Monday through Wednesday.

Performance Measures for Patients Hospitalized With Heart Failure: Are They Predictive of Clinical Outcomes?

Assessment of quality of care in heart failure (HF) has focused on the development and use of process of care-based performance measures. While it has been presumed that these process measures when applied in actual clinical practice are associated with improved clinical outcomes, this link has not been well-established. A recent analysis of the Organized Program to Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure (OPTIMIZE-HF) 1 registry/performance improvement program examined the relationship between current performance measures for patients hospitalized with HF and relevant patient clinical outcomes. This study found that none of the current HF performance measures were significantly associated with reduced early mortality risk and only angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge was associated with 60- to 90-day postdischarge mortality or rehospitalization. b-Blocker therapy at the time of hospital discharge, currently not an HF performance measure, was strongly associated with reduced risk of mortality and mortality/rehospitalization postdischarge. To accurately identify health care providers and hospitals providing care that is associated with more optimal clinical outcomes, additional HF performance measures as well as better methodology for identifying and validating performance measures is needed. HF is the leading cause of hospitalization in persons older than 65 years, with almost 3.6 million hospitalizations attributed to HF as the primary or a secondary discharge diagnosis each year. 2 HF patients are at substantial risk for recurrent exacerbations of symptoms requiring intervention, with up to 50% of discharged patients being rehospitalized within 6 months. An estimated 11.6% of HF patients die within 30 days and 33.1% of patients die within 1 year after their first hospitalization for HF. 3 Uniform highquality health care might reasonably be expected to reduce this burden of morbidity and mortality associated with HF. Evidence-based guidelines for the diagnosis and treatment of patients with HF have been developed. 2,4 To facilitate the measurement of and improvement in quality of care in HF, components of these guidelines have been adapted by the various organizations as performance measures. 5,6 These performance measures are based on clinical practice guidelines but are intended to be confined to those structural aspects or processes of care for which the evidence is so strong that the failure to perform them reduces the likelihood of optimal patient outcomes. 5 It is impor

Is Lower 30-Day Mortality Posthospital Admission Among Blacks Unique to the Veterans Affairs Health Care System?

Several studies have reported lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) health care system, particularly for those age 65 and older. This finding may be a result of the VA's integrated health care system, which reduces barriers to care through subsidized comprehensive health care services. However, no studies have directly compared racial differences in mortality within 30 days of hospitalization between the VA and non-VA facilities in the US health care system. To compare risk-adjusted 30-day mortality for black and white males after hospital admission to VA and non-VA hospitals, with separate comparisons for patients younger than age 65 and those age 65 and older. Retrospective observational study using hospital claims data from the national VA system and all non-VA hospitals in Pennsylvania and California. A total of 369,155 VA and 1,509,891 non-VA hospitalizations for a principal diagnosis of pneumonia, congestive heart failure, gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction between 1996 and 2001. Mortality within 30 days of hospital admission. Among those under age 65, blacks in VA and non-VA hospitals had similar odds ratios of 30-day mortality relative to whites for gastrointestinal bleeding, hip fracture, stroke, and acute myocardial infarction. Among those age 65 and older, blacks in both VA and non-VA hospitals had significantly reduced odds of 30-day mortality compared with whites for all conditions except pneumonia in the VA. The differences in mortality by race are remarkably similar in VA and non-VA settings. These findings suggest that factors associated with better short-term outcomes for blacks are not unique to the VA.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men

In response to a Congressional mandate to compare risk-adjusted surgical outcomes from Department of Veterans Affairs (VA) hospitals with those from private-sector hospitals, the National Surgical Quality Improvement Program was initiated in the VA system and then was developed in a select group of university medical centers in the private sector. This article analyzes risk-adjusted outcomes after vascular surgical operations in men performed at VA hospitals as compared with private-sector hospitals. This is a prospective cohort study of a sample of vascular surgical operations in men performed at 128 VA medical centers as compared with 14 university medical centers from October 1, 2001 to September 30, 2004. Patient and operative characteristics, and both unadjusted and risk-adjusted 30-day postoperative morbidity and mortality outcomes were compared. Data from 30,058 vascular operations in men at VA hospitals were compared with 5,174 cases performed at private-sector hospitals. The unadjusted 30-day mortality rate was notably lower in the VA system as compared with the private-sector group (3.4% versus 4.2%, p = 0.004). After risk-adjustment, there was no marked difference in mortality between the two hospital types. The unadjusted 30-day morbidity rate was also considerably lower in the VA hospitals as compared with the private sector (17.3% versus 22.3%, p < 0.0001). After risk-adjustment, morbidity in the VA system remained considerably lower than in the private sector, with an odds ratio of 0.84 (95% CI, 0.78 to 0.92). In vascular surgical operations in men, the VA hospitals demonstrated a lower risk-adjusted 30-day morbidity rate than the private-sector group. There is no marked difference in adjusted mortality rates between the two types of institutions.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Men

We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations. In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Women

In 1985, Congress mandated that the Department of Veterans Affairs (VA) compare its risk-adjusted surgical results with those in the private sector. The National Surgical Quality Improvement Program was developed as a result, in the VA system, and subsequently trialed in 14 university medical centers in the private sector. This report examines the results of the comparison between patient characteristics and outcomes of female general surgical patients in the two health care environments. Preoperative patient characteristics and laboratory variables, operative variables, and unadjusted postoperative outcomes were compared between VA and the private sector populations. In addition, stepwise logistic regression models were developed for 30-day postoperative mortality and morbidity. Finally, the effect of being treated in a VA or private sector hospital was assessed by adding an indicator variable to the models and testing it for statistical significance. Data from 5,157 female general surgical VA patients who underwent eligible procedures were compared with those from 27,467 patients in the private sector. Unadjusted 30-day mortality was virtually identical in the two groups (1.3%). The unadjusted morbidity rate was slightly, but notably, higher in the private sector (10.9%) as compared with that observed in the VA (8.5%, p < 0.0001). Predictive models were generated for mortality and morbidity combining both groups; top variables in these models were similar to those described previously in the National Surgical Quality Improvement Program. The indicator variable for system of care (VA versus private sector) was not statistically significant in the mortality model, but substantially favored the VA in the morbidity model (odds ratio=0.80, 95% CI=0.71, 0.90). The data demonstrate that in female general surgical patients, risk-adjusted mortality rates are comparable in the VA and the private sector, but risk-adjusted morbidity is higher in the private sector. Rates of urinary tract infections in the two populations may account for much of the latter difference.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Women

Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated. Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups. There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p=0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p < 0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p=0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI=0.44, 0.81). Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.

Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates

In response to concerns about the quality of care in US hospitals, the Centers for Medicare & Medicaid Services began measuring hospital performance and reporting this performance on their Web site, Hospital Compare. It is unknown whether these process performance measures are related to hospital-level outcomes. To determine whether quality measured with the process measures used in Hospital Compare are correlated with and predictive of hospitals' risk-adjusted mortality rates. Cross-sectional study of hospital care between January 1 and December 31, 2004, for acute myocardial infarction, heart failure, and pneumonia at acute care hospitals in the United States included on the Hospital Compare Web site. Ten process performance measures included in Hospital Compare were compared with hospital risk-adjusted mortality rates, which were measured using Medicare Part A claims data. Condition-specific inpatient, 30-day, and 1-year risk-adjusted mortality rates. A total of 3657 acute care hospitals were included in the study based on their performance as reported in Hospital Compare. Across all acute myocardial infarction performance measures, the absolute reduction in risk-adjusted mortality rates between hospitals performing in the 25th percentile vs those performing in the 75th percentile was 0.005 for inpatient mortality, 0.006 for 30-day mortality, and 0.012 for 1-year mortality (P<.001 for each comparison). For the heart failure performance measures, the absolute mortality reduction was smaller, ranging from 0.001 for inpatient mortality (P = .03) to 0.002 for 1-year mortality (P = .08). For the pneumonia performance measures, the absolute reduction in mortality ranged from 0.001 for 30-day mortality (P = .05) to 0.005 for inpatient mortality (P<.001). Differences in mortality rates for hospitals performing in the 75th percentile on all measures within a condition vs those performing lower than the 25th percentile on all reported measures for acute myocardial infarction ranged between 0.008 (P = .06) and 0.018 (P = .008). For pneumonia, the effects ranged between 0.003 (P = .09) and 0.014 (P<.001); for heart failure, the effects ranged between -0.013 (P = .06) and -0.038 (P = .45). Hospital performance measures predict small differences in hospital risk-adjusted mortality rates. Efforts should be made to develop performance measures that are tightly linked to patient outcomes.

Redirecting Patients to Improve Stroke Outcomes

The designation of primary stroke centers may result in patients being redirected from their usual source of care, although there is little evidence that these centers would result in better outcomes or lower costs. An alternative approach could direct patients to hospitals treating greater volumes of stroke patients. We sought to estimate the effect of hospital stroke volume on patient mortality and costs in a regional hospital market and to analyze the implications of hypothetical volume-based referral policies in that market, including the effects of patient-hospital distance. Using a retrospective cohort, we studied 12,150 Medicare patients admitted for acute stroke to 1 of 29 hospitals in Greater Cleveland during a 7-year period. The primary outcome was risk-adjusted 30-day mortality. Secondary outcomes included log hospital costs and discharge destination. The primary measure of volume was average annual number of stroke patients; patient distance to the nearest hospital was approximated using patient zip code and hospital address data. Overall 30-day mortality was 14.9%. For each 100-patient increase in hospitals' annual stroke volume, risk-adjusted mortality declined 0.9 percentage points (odds ratio = 0.90; 95% confidence interval = 0.82-0.98; P < 0.02) with no significant difference in hospital costs. For each 1-mile increase in patient distance to nearest hospital, mortality increased 0.6 percentage points (odds ratio = 1.07; 95% confidence interval = 1.03-1.11; P < 0.01). Only 3 of 29 hospitals (10.3%) exceeded the highest plausible threshold (250 strokes/year), redirecting 81.4% of patients for a net reduction in mortality of 0.4%; lower thresholds would redirect fewer patients but have negligible effects on mortality. Our findings fail to support redirecting acute stroke patients based on hospital stroke volume.

Impact of hospital nursing care on 30‐day mortality for acute medical patients

This paper reports on structures and processes of hospital care influencing 30-day mortality for acute medical patients. Wide variation in risk-adjusted 30-day hospital mortality rates for acute medical patients indicates that hospital structures and processes of care affect patient death. Because nurses provide the majority of care to hospitalized patients, we propose that structures and processes of nursing care have an impact on patient death or survival. A model hypothesizing the impact of nursing-related hospital care structures and processes on 30-day mortality was tested. Patient data from the Ontario, Canada Discharge Abstract Database 2002-2003, nurse data from the Ontario Nurse Survey 2003, and hospital staffing data from the Ontario Hospital Reporting System 2002-2003 files were used to develop indicators for variables hypothesized to impact 30-day mortality. Two multiple regression models were implemented to test the model. First, all variables were forced to enter the model simultaneously. Second, backward regression was implemented. Using backward regression, 45% of variance in risk-adjusted 30-day mortality rates was explained by eight predictors. Lower 30-day mortality rates were associated with hospitals that had a higher percentage of Registered Nurse staff, a higher percentage of baccalaureate-prepared nurses, a lower dose or amount of all categories of nursing staff per weighted patient case, higher nurse-reported adequacy of staffing and resources, higher use of care maps or protocols to guide patient care, higher nurse-reported care quality, lower nurse-reported adequacy of manager ability and support, and higher nurse burnout. Just as hospitals and clinicians caring for patients focus carefully on completing accurate diagnosis and appropriate and effective interventions, so too should hospitals carefully plan and manage structures and processes of care such as the proportion of Registered Nurses in the staff mix, percentage of baccalaureate-prepared nurses, and routine use of care maps to minimize unnecessary patient death.

Patient characteristics and hospital quality for colorectal cancer surgery

To assess associations of patient characteristics with quality-related characteristics of the hospitals where they were treated for colorectal cancer and the role of these associations in disparities in treatment quality affecting vulnerable patient groups or variations across health plans. Population-based cancer registry in California. A total of 38 237 patients diagnosed with stage I-III (non-metastatic) colorectal cancer in California between 1994 and 1998. Registry data were linked with hospital discharge abstracts, US census data, and Medicare enrollment data. The associations of patients' sociodemographic, clinical, and geographic covariates with treatment at high-volume institutions were assessed with logistic regression. The associations of patients' covariates with the risk-adjusted 30-day mortality rates of the hospitals where they received surgery were tested with linear regression. Patients with more advanced tumor stage or more extensive comorbidity, those of Hispanic or Asian race/ethnicity, and those from less affluent communities were less likely to undergo surgery at high-volume institutions and were treated at hospitals with higher risk-adjusted 30-day postoperative mortality rates than those who were less severely ill, white, or more affluent, respectively (all P < 0.05). Black patients also received surgery at hospitals with above-average mortality. Among patients 65 years and older, Medicare managed-care enrollees underwent surgery in higher-volume hospitals than Medicare fee-for-service enrollees, and there was substantial variation in hospital volume and adjusted hospital mortality among Medicare managed-care plans. Improving access of sicker, poorer, and minority patients to high-quality hospitals for cancer surgery may improve their outcomes. Further study of processes affecting hospital referral is warranted.

Public versus private institutional performance reporting: What is mandatory for quality improvement?

In the past 11 years, Ontario has generated institution-level performance report cards on outcomes of coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the differences in patient characteristics and outcomes observed during the transition from no reporting to confidential, and ultimately public performance report cards for CABG surgery in a public health system. We used clinical and administrative data to assess crude, expected, and risk-adjusted 30-day mortality rates after isolated CABG surgery in Ontario for 67693 patients from September 1, 1991, to March 31, 2002. Confidence intervals on relative mortality reductions were determined by bootstrapping. We compared 30-day mortality trends to a control outcome (risk-adjusted 30-day all-cause readmission). We analyzed inhospital mortality trends for Ontario compared with the rest of Canada for the period from 1992 to 1998. The risk-adjusted 30-day mortality rate decreased 29% (95% CI 21-39) from the era of no reporting (1991-1993) to confidential reporting (1994-1998). There was no further decrease with public reporting (1999-2001). The control outcome of 30-day readmission did not decrease across reporting eras. Inhospital mortality fell significantly faster in Ontario during the period of confidential reporting than in other parts of Canada. Ontario CABG mortality outcomes improved sharply after provider results were confidentially disclosed at an institutional level. No such changes were seen for nondisclosed outcomes or regions outside Ontario. Further public reporting of outcomes had no discernible impact on performance. These results are consistent with the hypothesis that confidential disclosure of outcomes was sufficient to accelerate quality improvement in a public system with little competition for patients between hospitals.

Exploring the Volume-Outcome Relationship for Off-Pump Coronary Artery Bypass Graft Procedures

The relationship between the surgical case volume and risk-adjusted clinical outcomes has been examined for different surgical specialties. The purpose of this study was to explore the relationship between the off-pump coronary artery bypass graft procedure volumes (OPCABG) with risk-adjusted outcomes within the Department of Veterans Affairs (VA) 44 cardiac surgery programs. Based on VA Continuous Improvement in Cardiac Surgery Program data, the results of 5,076 OPCABG surgical procedures performed between October 1998 and September 2003 were analyzed. Hierarchical logistic regression models evaluated the relationship between OPCABG procedure volume with risk-adjusted 30-day operative mortality, perioperative morbidity, and 180-day mortality. Both a hospital's average OPCABG volume per 6-month period and the hospital's most recent 6-month OPCABG volume were examined. Hospital OPCABG average volume in a 6-month period ranged from 0.2 to 47.4 procedures; whereas the most recent 6-month OPCABG hospital volume ranged from 0 to 76 OPCABG per site. No relationship between the volume measures and the outcome variables was found. We did not find an association between OPCABG volume with short-term mortality, perioperative morbidity, or intermediate-term (180-day) mortality.

Massachusetts Cardiac Surgery Report Card: Implications of Statistical Methodology

Choice of statistical methodology may significantly impact the results of provider profiling, including cardiac surgery report cards. Because of sample size and clustering issues, logistic regression may overestimate systematic interprovider variability, leading to false outlier classification. Theoretically, the use of hierarchical models should result in more accurate representation of provider performance. Extensively validated and audited data were available for all 4,603 isolated coronary artery bypass grafting procedures performed at 13 Massachusetts hospitals during 2002. To produce the official Massachusetts cardiac surgery report card, a 19-variable predictor set and a hierarchical generalized linear model were employed. For the current study, this same analysis was repeated with the 14 predictors used in the New York Cardiac Surgery Reporting System. Two additional analyses were conducted using each set of predictor variables and applying standard logistic regression. For each of the four combinations of predictors and models, the point estimates of risk-adjusted 30-day mortality, 95% confidence or probability intervals, and outlier status were determined for each hospital. Overall unadjusted mortality for coronary bypass operations was 2.19%. For most hospitals, there was wide variability in the point estimates and confidence or probability intervals of risk-adjusted mortality depending on statistical model, but little variability relative to the choice of predictors. There were no hospital outliers using hierarchical models, but there was one outlier using logistic regression with either predictor set. When used to compare provider performance, logistic regression increases the possibility of false outlier classification. The use of hierarchical models is recommended.

Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty.

The utilization of joint arthroplasty for knee or hip osteoarthritis varies markedly by patient race/ethnicity. Because of concerns about surgical risk, black patients are less willing to consider this treatment. There are few published race/ethnicity-specific data on joint arthroplasty outcomes. The present study was undertaken to examine racial/ethnic differences in mortality and morbidity following elective knee or hip arthroplasty. Using information from the Veterans Administration National Surgical Quality Improvement Program database, data on 12,108 patients who underwent knee arthroplasty and 6,703 patients who underwent hip arthroplasty over a 5-year period were analyzed. Racial/ethnic differences were determined using prospectively collected data on patient characteristics, procedures, and short-term outcomes. The main outcome measures were risk-adjusted 30-day mortality and complication rates. Adjusted rates of both non-infection-related and infection-related complications after knee arthroplasty were higher among black patients compared with white patients (relative risk [RR] 1.50, 95% confidence interval [95% CI] 1.08-2.10 and RR 1.42, 95% CI 1.06-1.90, respectively). Hispanic patients had a significantly higher risk of infection-related complications after knee arthroplasty (RR 1.64, 95% CI 1.08-2.49) relative to otherwise similar white patients. Race/ethnicity was not significantly associated with the risk of non-infection-related complications (RR 0.97, 95% CI 0.68-1.38 in blacks; RR 1.18, 95% CI 0.60-2.30 in Hispanics) or infection-related complications (RR 1.27, 95% CI 0.91-1.78 in blacks; RR 1.22, 95% CI 0.63-2.36 in Hispanics) after hip arthroplasty. The overall 30-day mortality was 0.6% following knee arthroplasty and 0.7% following hip arthroplasty, with no significant differences by race/ethnicity observed for either procedure. Although absolute risks of complication are low, our findings indicate that, after adjustment, black patients have significantly higher rates of infection-related and non-infection-related complications following knee arthroplasty, compared with white patients. In addition, adjusted rates of infection-related complications after knee arthroplasty are higher in Hispanic patients than in white patients. Such differences between ethnic groups are not seen following hip arthroplasty. These groups do not appear to differ significantly in terms of post-arthroplasty mortality rates.

Surgical patients are at lower risk of death in hospitals with more degree-educated nurses

Question What is the relationship between the education level of hospital nurses and risk-adjusted 30-day mortality in surgical patients? Study design Outcomes analysis using questionnaire and hospital discharge data. Main results Risk of 30-day mortality reduced by 5% when the proportion of degree-educated nurses increased by 10% ( p⩽0.02). A mean workload increase of one patient per nurse increased risk of 30-day mortality by 5% ( p⩽0.03). Hospitals with more degree-educated nurses were: larger, more likely to undertake advanced surgical techniques ( p<0.001), more commonly teaching hospitals and had lower mean work loads ( p<0.001). Length of nursing experience was not found to be a predictor of mortality ( p>0.52). Authors’ conclusions People were less likely to die after surgery in hospitals with a higher proportion of degree-educated nurses.

Developing risk-adjusted 30-day hospital mortality rates.

This article describes one risk-adjustment method useful for minimizing threats to internal validity that stem from the impact on the outcomes under investigation from patients' own characteristics and their associated risks. Mortality is the outcome used to illustrate the risk-adjustment approach. A two-step approach to outcomes research is suggested. The first step includes risk-adjusting outcomes for patient characteristics by developing standard mortality rates. In the second step these risk-adjusted standard rates can be used as dependent variables in outcomes analytic models. This article focuses on the first step. In the current study risk adjustment resulted in changes in both absolute values and rank ordering of hospital mortality rates compared to crude rates. This procedure is useful for developing risk-adjusted outcomes with administrative data similar to those used in this study.