Case-mix Adjustment Research Articles

External validation of inpatient neonatal mortality prediction models in high-mortality settings

BackgroundTwo neonatal mortality prediction models, the Neonatal Essential Treatment Score (NETS) which uses treatments prescribed at admission and the Score for Essential Neonatal Symptoms and Signs (SENSS) which uses basic clinical signs, were derived in high-mortality, low-resource settings to utilise data more likely to be available in these settings. In this study, we evaluate the predictive accuracy of two neonatal prediction models for all-cause in-hospital mortality.MethodsWe used retrospectively collected routine clinical data recorded by duty clinicians at admission from 16 Kenyan hospitals used to externally validate and update the SENSS and NETS models that were initially developed from the data from the largest Kenyan maternity hospital to predict in-hospital mortality. Model performance was evaluated by assessing discrimination and calibration. Discrimination, the ability of the model to differentiate between those with and without the outcome, was measured using the c-statistic. Calibration, the agreement between predictions from the model and what was observed, was measured using the calibration intercept and slope (with values of 0 and 1 denoting perfect calibration).ResultsAt initial external validation, the estimated mortality risks from the original SENSS and NETS models were markedly overestimated with calibration intercepts of − 0.703 (95% CI − 0.738 to − 0.669) and − 1.109 (95% CI − 1.148 to − 1.069) and too extreme with calibration slopes of 0.565 (95% CI 0.552 to 0.577) and 0.466 (95% CI 0.451 to 0.480), respectively. After model updating, the calibration of the model improved. The updated SENSS and NETS models had calibration intercepts of 0.311 (95% CI 0.282 to 0.350) and 0.032 (95% CI − 0.002 to 0.066) and calibration slopes of 1.029 (95% CI 1.006 to 1.051) and 0.799 (95% CI 0.774 to 0.823), respectively, while showing good discrimination with c-statistics of 0.834 (95% CI 0.829 to 0.839) and 0.775 (95% CI 0.768 to 0.782), respectively. The overall calibration performance of the updated SENSS and NETS models was better than any existing neonatal in-hospital mortality prediction models externally validated for settings comparable to Kenya.ConclusionFew prediction models undergo rigorous external validation. We show how external validation using data from multiple locations enables model updating and improving their performance and potential value. The improved models indicate it is possible to predict in-hospital mortality using either treatments or signs and symptoms derived from routine neonatal data from low-resource hospital settings also making possible their use for case-mix adjustment when contrasting similar hospital settings.

Impact of the first wave of COVID-19 on outcomes following emergency admissions for common acute surgical conditions: analysis of a national database in England.

BackgroundThis study assessed the impact of the first COVID-19 wave in England on outcomes for acute appendicitis, gallstone disease, intestinal obstruction, diverticular disease, and abdominal wall hernia.MethodsEmergency surgical admissions for patients aged 18 years and older to 124 NHS Trust hospitals between January and June in 2019 and 2020 were extracted from Hospital Episode Statistics. The risk of 90-day mortality after admission during weeks 11–19 in 2020 (national lockdown) and 2019 (pre-COVID-19) was estimated using multilevel logistic regression with case-mix adjustment. The primary outcome was all-cause mortality at 90 days.ResultsThere were 12 231 emergency admissions and 564 deaths within 90 days during weeks 11–19 in 2020, compared with 18 428 admissions and 542 deaths in the same interval in 2019. Overall, 90-day mortality was higher in 2020 versus 2019, with an adjusted OR of 1.95 (95 per cent c.i. 0.78 to 4.89) for appendicitis, 2.66 (1.81 to 3.92) for gallstone disease, 1.99 (1.44 to 2.74) for diverticular disease, 1.70 (1.13 to 2.55) for hernia, and 1.22 (1.01 to 1.47) for intestinal obstruction. After emergency surgery, 90-day mortality was higher in 2020 versus 2019 for gallstone disease (OR 3.37, 1.26 to 9.02), diverticular disease (OR 2.35, 1.16 to 4.73), and hernia (OR 2.34, 1.23 to 4.45). For intestinal obstruction, the corresponding OR was 0.91 (0.59 to 1.41). For admissions not leading to emergency surgery, mortality was higher in 2020 versus 2019 for gallstone disease (OR 2.55, 1.67 to 3.88), diverticular disease (1.90, 1.32 to 2.73), and intestinal obstruction (OR 1.30, 1.06 to 1.60).ConclusionEmergency admission was reduced during the first lockdown in England and this was associated with higher 90-day mortality.

The Association of Modifiable Postresuscitation Management and Annual Case Volume With Survival After Extracorporeal Cardiopulmonary Resuscitation

IMPORTANCE:It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes.OBJECTIVES:To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival.DESIGN:Observational cohort study using case-mix adjusted survival analysis.SETTING AND PARTICIPANTS:Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019.MAIN OUTCOMES AND MEASURES:Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR.RESULTS:Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44–64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08–1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11– 1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05–1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04–1.45; p = 0.015) versus medium- and low-volume centers.CONCLUSIONS AND RELEVANCE:Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature.

Fistula Risk Score for Auditing Pancreatoduodenectomy: The Auditing-FRS.

To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals. For proper comparisons of outcomes in surgical audits, case-mix variation should be accounted for. This study included consecutive patients after pancreatoduodenectomy from the mandatory nationwide Dutch Pancreatic Cancer Audit. Derivation of the score was performed with the data from 2014 to 2018 and validation with 2019 to 2020 data. The primary endpoint of the study was POPF (grade B or C). Multivariable logistic regression analysis was performed for case-mix adjustment of known risk factors. In the derivation cohort, 3271 patients were included, of whom 479 (14.6%) developed POPF. Male sex [odds ratio (OR)=1.34; 95% confidence interval (CI): 1.09-1.66], higher body mass index (OR=1.07; 95% CI: 1.05-1.10), a final diagnosis other than pancreatic ductal adenocarcinoma/pancreatitis (OR=2.41; 95% CI: 1.90-3.06), and a smaller duct diameter (OR=1.43/mm decrease; 95% CI: 1.32-1.55) were independently associated with POPF. Diabetes mellitus (OR=0.73; 95% CI: 0.55-0.98) was independently associated with a decreased risk of POPF. Model discrimination was good with a C -statistic of 0.73 in the derivation cohort and 0.75 in the validation cohort (n=913). Hospitals differed in particular in the proportion of pancreatic ductal adenocarcinoma/pancreatitis patients, ranging from 36.0% to 58.1%. The observed POPF risk per center ranged from 2.9% to 25.4%. The expected POPF rate based on the 5 risk factors ranged from 11.6% to 18.0% among hospitals. The auditing fistula risk score was successful in case-mix adjustment and enables fair comparisons of POPF rates among hospitals.

Feedback of aggregate patient-reported outcomes (PROs) data to clinicians and hospital end users: findings from an Australian codesign workshop process

ObjectivesPatient-reported outcomes (PROs) are increasingly used to measure the patient’s perspective of their outcomes following healthcare interventions. The aim of this study was to determine the preferred formats for reporting...

Age and Charlson Comorbidity Index score are not independent risk factors for severe complications after curative esophagectomy for esophageal cancer: a Dutch population-based cohort study

BackgroundThe number of older patients undergoing curative esophagectomy for esophageal cancer is increasing, and minimally invasive techniques are being increasingly used. The aim of this study is to compare postoperative outcomes after curative esophagectomy between older and younger patients. MethodsData was retrieved from the Dutch Upper Gastrointestinal Cancer Audit (DUCA), a national surgical outcome registry. The primary outcome was severe complications, defined as complications graded Clavien-Dindo ≥ 3. The secondary outcomes were postoperative complications, reintervention rates, length of hospital stays, and mortality. Outcomes were compared between patients aged ≥75 and < 75 years. We performed additional subgroup analyses between these age groups after totally minimally invasive esophagectomy (TMIE) and in patients with severe complications. We adjusted for the following parameters: gender, BMI, Charlson Comorbidity Index score (CCI), ASA score, histology, type of neoadjuvant therapy, and surgical technique. ResultsOf all 3775 included patients, 455 (12.1%) were aged ≥75 years and 3302 (87.9%) were aged <75 years. Overall, severe complications occurred in 184 (40.4%) older and in 1140 (34.5%) younger patients (CI = 1.009–1.080). After TMIE, severe complications occurred in 150 (42.1%) older and in 891 (35.8%) younger patients (CI = 1.007–1.088). In patients with severe complications, rates of complications, reinterventions, mortality, and ICU stays were comparable between older and younger patients. After adjustment for casemix, age and CCI score were not independent risk factors for (severe) complications and mortality. ConclusionsAge and Charlson Comorbidity Index are not adequate predictors of postoperative morbidity and mortality after curative esophagectomy for esophageal cancer.

Defining Textbook Outcome in liver surgery and assessment of hospital variation: A nationwide population-based study

IntroductionTextbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to assess factors associated with TO, and evaluate hospital and network variation after case-mix correction in TO rates for liver surgery. MethodsThis was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of hospital stay, and readmission, and obtaining adequate resection margins. Multivariable logistic regression was used for case-mix adjustment. Results2376 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51–0.95 p = 0.02), extrahepatic disease (aOR 0.64, CI 0.44–0.95, p = 0.02), tumour size >55 mm on preoperative imaging (aOR 0.56, CI 0.34–0.94, p = 0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54–0.98, p = 0.04), and major liver resection (aOR 0.50, CI 0.36–0.69, p < 0.001). After case-mix correction, no significant hospital or oncological network variation was observed. ConclusionTO differs between indications for liver resection and can be used to assess between hospital and network differences.

International variation in length of stay in intensive care units and the impact of patient-to-nurse ratios

ObjectiveTo assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark. DesignSecondary analysis of the DecubICUs trial (performed on 15 May 2018). SettingThe study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included. Main outcome measureMultivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves. ResultsPatients had a median ICU length of stay of 11 days (interquartile range, 4–27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35–0.51) for Greece, to maximaly1.94 (1.28–2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94–0.98), indicating that higher patient-to-nurse ratio results in longer length of stay. ConclusionsDespite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.

Associations with visual acuity outcomes after 12 months of treatment in 9401 eyes with neovascular AMD

ObjectiveTo record visual acuity outcomes after 12 months of treatment for neovascular age-related macular degeneration (NvAMD), investigate variation between sites and explore associations with baseline characteristics and care processes.Methods and...

Movement Difficulties at Age Five Among Extremely Preterm Infants.

Children born extremely preterm (EPT), <28 weeks' gestational age, face higher risks of movement difficulties than their term-born peers. Studies report varying prevalence estimates and prognostic factors identifying children who could benefit from early intervention are inconsistent. This study investigated the prevalence of movement difficulties in children born EPT and associated risk factors. Data come from a population-based EPT birth cohort in 2011 and 2012 in 11 European countries. Children without cerebral palsy were assessed at 5 years of age (N = 772) with the Movement Assessment Battery for Children-Second Edition, which classifies movement difficulties as none (>15th percentile), at risk (6th-15th percentile) and significant (≤5th percentile). Associations with sociodemographic, perinatal, and neonatal characteristics collected from obstetric and neonatal medical records and parental questionnaires were estimated using multinomial logistic regression. We found 23.2% (n = 179) of children were at risk for movement difficulties and 31.7% (n = 244) had significant movement difficulties. Lower gestational age, severe brain lesions, and receipt of postnatal corticosteroids were associated with significant movement difficulties, whereas male sex and bronchopulmonary dysplasia were associated with being at risk and having significant movement difficulties. Children with younger, primiparous, less educated, and non-European-born mothers were more likely to have significant movement difficulties. Differences in prevalence between countries remained after population case-mix adjustments. This study confirms a high prevalence of movement difficulties among EPT children without cerebral palsy, which are associated with perinatal and neonatal risk factors as well as sociodemographic characteristics and country.

Thepresenceofaurinarycatheterisanimportantpredictorofin-hospitalmortalityininternalmedicinepatients.

Mortality rates are used to assess the quality of hospital care after appropriate adjustment for case-mix. Urinary catheters are frequent in hospitalized adults and might be a marker of patient frailty and illness severity. However, we know of no attempts to estimate the predictive value of indwelling catheters for specific patient outcomes. The objective of the present study was to (a) identify the variables associated with the presence of a urinary catheter and (b) determine whether it predicts in-hospital mortality after adjustment for these variables. The study population included all acutely admitted adult patients in 2020 (exploratory cohort) and January-October 2021 (validation cohort) to internal medicine, cardiologyand intensive care departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. There were no exclusion criteria. The predictor variables were the presence of a urinary catheter on admission, age, gender, comorbiditiesand admission laboratory test results. We used bivariate and multivariate logistic regression to test the associations between the presence of a urinary catheter and mortality after adjustment for the remaining independent variables on admission. The presence of a urinary catheter was associated with other independent variables. In 2020, the odds of in-hospital mortality in patients with a urinary catheter before and after adjustment for the remaining predictors were 14.3 (11.6-17.7) and 6.05 (4.78-7.65), respectively. Adding the presence of a urinary catheter to the prediction logistic regression model increased its c-statistic from 0.887 (0.880-0.894) to 0.907 (0.901-0.913). The results of the validation cohort reduplicated those of the exploratory cohort. The presence of a urinary catheter on admission is an important and independent predictor of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

MO506: Disparities in Hospitalisation Rates Between Men and Women With and Without Chronic Kidney Disease in the Irish Health System

Abstract BACKGROUND AND AIMS It is increasingly recognized that disparities in health care utilisation and associated clinical outcomes exist between men and women. Whether these sex disparities extend to patients with chronic kidney disease (CKD) is not well known. The primary goal of this study was to compare hospitalisation rates between men and women in the Irish health system and study the association of kidney function with hospitalization rates. METHOD We constructed a cohort of 125 890 patients from the National Kidney Disease Surveillance System (NKDSS) to compare hospitalization rates between men and women. Patients were recruited from 1 January 2005 to 31 December 2010 and followed until 31 December 2013. Hospitalization events were captured from the National Hospital In-Patient Enquiry (HIPE) system and linked to existing laboratory data systems. The primary cause of hospitalization was determined from the International Classification of Diseases (ICD-10), with causes grouped according to Major Diagnostic Categories (MDC). CKD was defined as an eGFR &amp;lt;60 mL/min/1.72 m2. Crude rates were calculated as the total number of hospitalizations that occurred during follow-up divided by the total number of observed person-years. Negative binomial regression determined rate ratios (RR) for men versus women with adjustment for baseline casemix. The principal exposure was participant sex, classified as men or women. RESULTS Of the 125 890 participants, 55.1% were women, with a mean age of 54.1 (SD: 17.7) years. Compared with women, men were on average significantly older (55.1 versis 53.3 years), had higher eGFR (83.3 versus 82.4 mL/min/1.72 m2), more diabetes (22.9% versus 17.0%) and higher levels of inflammatory markers (P &amp;lt; .001 for all). During a median follow-up of 7.7 years, there were 93 515 hospitalizations. Crude hospitalization rates (per 100 person years) were marginally higher in men than in women {11.1, [95% confidence interval (95% CI) 11.0–1.2 versus 9.8), 95% CI 9.70–9.9/100 pyr]} in the overall cohort, which changed little with adjustment for age. With each worsening category of kidney function, hospitalization rates increased substantially from 8.1 (8.0–8.3) to 28.6 (27.0–30.3) in men and from 8.1 (8.0–8.3) to 24.7 (23.5–25.9) in women, respectively. However, within each category, rates of hospitalization were significantly higher for men than for women (P-value interaction, &amp;lt;.001). In stratified analyses, the men-to-women risk ratios increased from 1.11 (1.02–1.21) for eGFR &amp;gt;90 mL/min to 1.50 (1.34–1.68) for GFR 45–59 mL/min/m² (Table 1). A similar pattern was observed when the 60 mL/min eGFR threshold was used (Table 1). The excess hospitalizations in men compared with women were in general due to higher rates of hospitalizations from circulatory disorders (5.2 versus 3.2/100 pyr), respiratory illness (4.0 versus 2.8/100 pyr), and diseases of the digestive system (2.5 versus 2.0/100 pyr), as shown in Fig. 1. CONCLUSION Men and women with CKD experienced hospitalization rates that were far higher than those without CKD. Hospitalization rates were greater in men than women across all stages of CKD, which was not explained by age or acute illness indicators. The excess hospitalizations in men were largely attributed to common cardio-respiratory-digestive illnesses. CKD is a major risk amplifier for hospitalization in both men and women and should be identified in all patients prior to hospitalization to ensure effective risk stratification and optimal management.

Development of a data-driven case-mix adjustment model for comparison of hospital performance in hip fracture care

SummaryTo compare hospitals’ hip fracture patient mortality in a quality of care registry, correction for patient characteristics is needed. This study evaluates in 39,374 patients which characteristics are associated with 30 and 90-day mortality, and showed how using these characteristics in a case mix-model changes hospital comparisons within the Netherlands.PurposeMortality rates after hip fracture surgery are considerable and may be influenced by patient characteristics. This study aims to evaluate hospital variation regarding patient demographics and disease burden, to develop a case-mix adjustment model to analyse differences in hip fracture patients’ mortality to calculate case-mix adjusted hospital-specific mortality rates.MethodsData were derived from 64 hospitals participating in the Dutch Hip Fracture Audit (DHFA). Adult hip fracture patients registered in 2017–2019 were included. Variation of case-mix factors between hospitals was analysed, and the association between case-mix factors and mortality at 30 and 90 days was determined through regression models.ResultsThere were 39,374 patients included. Significant variation in case-mix factors amongst hospitals was found for age ≥ 80 (range 25.8–72.1% p < 0.001), male gender (12.0–52.9% p < 0.001), nursing home residents (42.0–57.9% p < 0.001), pre-fracture mobility aid use (9.9–86.7% p < 0,001), daily living dependency (27.5–96.5% p < 0,001), ASA-class ≥ 3 (25.8–83.3% p < 0.001), dementia (3.6–28.6% p < 0.001), osteoporosis (0.0–57.1% p < 0.001), risk of malnutrition (0.0–29.2% p < 0.001) and fracture types (all p < 0.001). All factors were associated with 30- and 90-day mortality. Eight hospitals showed higher and six showed lower 30-day mortality than expected based on their case-mix. Six hospitals showed higher and seven lower 90-day mortality than expected. The specific outlier hospitals changed when correcting for case-mix factors.ConclusionsDutch hospitals show significant case-mix variation regarding hip fracture patients. Case-mix adjustment is a prerequisite when comparing hospitals’ 30-day and 90-day hip fracture patients’ mortality. Adjusted mortality may serve as a starting point for improving hip fracture care.

Patient outcomes related to receiving care on a dedicated Acute Care for Elders (ACE) unit versus with an ACE order set.

The Acute Care for Elders (ACE) unit model of care aims to reduce common complications of hospitalization in older adults through early involvement of allied health providers, changes to the care environment, elder-friendly care protocols, and proactive discharge planning. Our hospital established a dedicated 28-bed medical ACE unit. Because of capacity limitations, the number of eligible older medical patients often exceeds the available number of beds. Thus, some ACE unit-eligible patients are instead admitted to other medical or surgical units for their medical care. These "bed-spaced" ACE patients receive care by the same general internists and ACE order set that ACE unit patients are cared under. We sought to compare the health outcomes of ACE-designated patients admitted to the ACE unit versus bed-spaced peers cared for using a protocolized ACE order set. 3046 ACE-designated patient admissions were analyzed (1499 ACE unit and 1547 bed-spaced). The primary outcomes examined were discharge disposition and in-hospital mortality. Univariate and multivariate comparisons were performed. Propensity matching was used to adjust for case mix in a post-hoc analysis. The mean age of participants was 83.5 years for ACE unit patients and 82.6 for bedspaced patients. In adjusted models, ACE unit patients were more likely to be discharged home (OR 1.28 [1.08-1.50], p=0.003). In an unadjusted analysis, patients admitted to ACE unit were less likely to die in hospital, but this finding did not persist after adjustment for case mix. Care of older adults delivered on a dedicated ACE unit increases the likelihood of discharge to home when compared to care delivered with an ACE order set alone for general internal medicine patients.

Variation in Hospital Cost and 1-Year Episodes of Care after Diaphragmatic Hernia Repair.

Diaphragmatic hernia repair is a common operation performed at all types of hospitals. The variation in costs and repeat episodes of care after this operation is not known. The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing diaphragmatic hernia repair between 2011 and 2018 and the associated inpatient and outpatient encounters within 12 months postoperatively. Hospitals were ranked by cost and grouped into quintiles. All costs and charges were reliability and case-mix adjusted with the use of hierarchical multivariable regression. In total, 8,848 patients underwent diaphragmatic hernia operations at 158 hospitals. The most expensive hospital quintile had lower surgical volume, location in rural settings, and fewer than 100 beds. There was a wide variation in costs after diaphragmatic hernia repair. On unadjusted comparison, index costs were $23,041 more expensive in hospitals in the highest quintile than in the lowest quintile. Cost differences were persistent even after case-mix and reliability adjustment. The variation in adjusted aggregate charges for associated outpatient and inpatient encounters in the first year after the index operation was considerably lower than that of the index hospitalization. There is nearly a 2-fold variation in the cost of a diaphragmatic hernia repair across hospitals. Most of the variation occurs during the index surgical encounter and not for repeat encounters during the first postoperative year. As bundled payment models mature, hospitals and payers will need to target this variation to ensure cost-efficiency.

International comparison of variation in performance between hospitals for THA and TKA: Is it even possible? A systematic review including 33 studies and 8 arthroplasty register reports.

In order to improve care for total hip and knee arthroplasties (THA/TKA), hospitals may want to compare their performance with hospitals in other countries. Pooling data across countries also enable early detection of infrequently occurring safety issues. We therefore aimed to assess the between-hospital variation and definitions used for revision, readmission, and complications across countries.PubMed, Embase, Web of Science, Cochrane library, Emcare, and Academic Search Premier were searched from January 2009 to August 2020 for studies reporting on: (i) primary THA/TKA; (ii) revision, readmission, or complications; and (iii) between-hospital variation. Most recent registry reports of Network of Orthopedic Registries of Europe members were also reviewed. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the Integrated quality Criteria for the Review Of Multiple Study designs tool for studies and relevant domains for registries. We assessed agreement for the following domains: (i) outcome definition; (ii) follow-up and starting point; (iii) case-mix adjustment; and (iv) type of patients and hospitals included.Between-hospital variation was reported in 33 (1 high-quality, 13 moderate-quality, and 19 low-quality) studies and 8 registry reports. The range of variation for revision was 0–33% for THA and 0–27% for TKA varying between assessment within hospital admission until 10 years of follow-up; for readmission, 0–40% and 0–32% for THA and TKA, respectively; and for complications, 0–75% and 0–50% for THA and TKA, respectively. Indicator definitions and methodological variables varied considerably across domains.The large heterogeneity in definitions and methods used likely explains the considerable variation in between-hospital variation reported for revision, readmission, and complications , making it impossible to benchmark hospitals across countries or pool data for earlier detection of safety issues. It is necessary to collaborate internationally and strive for more uniformity in indicator definitions and methods in order to achieve reliable international benchmarking in the future.

The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

Research questionGiven the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival? MethodsObservational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival. ResultsHospital survival was decreased with higher PaO2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. ConclusionLower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. National Institute for Health Research Global Health Research Group.

Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard.

Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers. This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data. We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation. The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data. A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

Mortality Prediction After Cardiac Surgery in Children: An STS Congenital Heart Surgery Database Analysis

BackgroundThe Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) provides risk-adjusted operative mortality rates to approximately 120 North American congenital heart centers. Optimal case-mix adjustment methods for operative mortality risk prediction in this population remain unclear. MethodsA panel created diagnosis-procedure combinations of encounters in the CHSD. Models for operative mortality using the new diagnosis-procedure categories, procedure-specific risk factors, and syndromes or abnormalities included in the CHSD were estimated using Bayesian additive regression trees and least absolute shrinkage and selector operator (lasso) models. Performance of the new models was compared with the current STS CHSD risk model. ResultsOf 98 825 operative encounters (69 063 training; 29 762 testing), 2818 (2.85%) STS-defined operative mortalities were observed. Differences in sensitivity, specificity, and true and false positive predicted values were negligible across models. Calibration for mortality predictions at the higher end of risk from the lasso and Bayesian additive regression trees models was better than predictions from the STS CHSD model, likely because of the new models’ inclusion of diagnosis-palliative procedure variables affecting <1% of patients overall but accounting for 27% of mortalities. Model discrimination varied across models for high-risk procedures, hospital volume, and hospitals. ConclusionsOverall performance of the new models did not differ meaningfully from the STS CHSD risk model. Adding procedure-specific risk factors and allowing diagnosis to modify predicted risk for palliative operations may augment model performance for very high-risk surgical procedures. Given the importance of risk adjustment in estimating hospital quality, a comparative assessment of surgical program quality evaluations using the different models is warranted.