Health Services Cost Review Commission Research Articles

Percentage of Mortal Encounters Transferred in Emergency General Surgery

BackgroundDespite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters. Materials and methodsA retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital. ResultsOverall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = −0.57). ConclusionsBroad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.

Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland's All-Payer Program: An Observational Study.

Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear. To examine the independent contributions of the patient's neighborhood and the hospital's service area to risk for 30-day readmission. Retrospective observational study. Maryland. All Maryland residents discharged from a Maryland hospital in 2015. Predictors included the disadvantage of neighborhoods for each Maryland resident (area disadvantage index) and the mean disadvantage of each hospital's discharged patients (safety-net index). The primary outcome was unplanned 30-day hospital readmission. Generalized estimating equations and marginal modeling were used to estimate readmission rates. Results were adjusted for clinical readmission risk. 13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (CI, 13.4% to 16.1%) compared with 11.6% (CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status. The association of readmission risk with the hospital's safety-net index was approximately twice the observed association with the patient's neighborhood disadvantage status. Generalizability outside Maryland is unknown. Confounding may be present. In Maryland, residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission. National Institute on Minority Health and Health Disparities and Maryland Health Services Cost Review Commission.

Interhospital Transfers with Wide Variability in Emergency General Surgery

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume (P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume (P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

The effects of global budget payments on hospital utilization in rural Maryland.

To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population-level hospital rates of utilization three years after implementation. Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county-level data from the Area Health Resource File. We use a difference-in-differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. Admissions data are hospital-reported discharge abstracts of all encounters in Maryland during 2008-2013. Population data are derived from the US Census. We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.

SAT-138 Predictors and Health Care Expenditures Associated with Recurrent Diabetic Ketoacidosis Admissions in Adults with Type 1 Diabetes

Introduction: Diabetic ketoacidosis (DKA) is a serious complication in patients with type 1 diabetes (T1D). Recurrent DKA admissions have been associated with increased mortality and substantial healthcare costs. In contrast to pediatrics, significantly less attention has been devoted to exploring and addressing recurrent DKA admissions in adults with T1D. We aimed to characterize the adult population of T1D admitted with DKA in Maryland, identify predictors of recurrent DKA admissions, and quantify their associated healthcare costs. Methods: We conducted a cross-sectional study using the Maryland Health Services Cost Review Commission's database, which collects data from all acute care hospitals in the state. We defined DKA using ICD diagnostic codes for ketoacidosis and hyperosmolality in T1D. We selected adult patients (age 20 or above) with T1D who lived in or bordering Maryland and had at least one admission with a primary diagnosis of DKA between January 1, 2012 and December 31, 2017. The predictors analyzed in this study represent patient characteristics from the first DKA admission. The primary outcome was readmission for DKA in the study period. The summation of admission charges was used to calculate DKA healthcare expenditures. Results: There were 6,147 DKA admissions by 3,368 T1D adults admitted in Maryland in the study period. Readmissions occurred in 915 (27%) patients, with 1-3 and >4 readmissions occurring in 700 (76%) and 487 (24%) of these patients, respectively. Overall, the patients admitted with DKA were predominately non-Hispanic (96%) white (45%) or black (45%) men (53%) between the ages 20-39 years old (48%) from areas of low to moderate socioeconomic status (SES). The majority of patients were insured by private (37%) and Medicaid (27%) insurance. The strongest predictors for DKA readmissions were female sex (OR 1.3; 95%CI 1.1-1.6), residing in an area of low SES (OR 1.5; 95% 1.1-2.0), being insured by Medicare (OR 1.7; 95%CI 1.3-2.2), Medicaid (OR 1.5 95%CI 1.2-1.8) or Self-pay/charity (OR 1.5; 95%CI 1.1-1.9), and discharge against medical advice (OR 1.6; 95%CI 1.2-2.3). Older and non-white patients had a reduced odds of readmission. The expenditure of all adult DKA admissions totaled 5.4 billion dollars. While patients who had DKA readmissions consisted of only 27% of those admitted with DKA, their total costs were 59% of these DKA charges at 3.2 billion dollars. Conclusion: There is a high prevalence of recurrent DKA admissions in adults with T1D. Younger patients, women, having non-private insurance and those living in areas of low SES have the highest odds for readmission. Although these patients are a minority, they account for a majority of DKA health expenditures. Further studies are needed to understand drivers of these admissions in order to intervene in this population at high risk for poor outcomes. Supported by a NIH T32 Grant T32 and Saudek Fellowship Award.

Is there evidence of a July effect among patients undergoing hysterectomy surgery?

It is hypothesized that the quality of health care decreases during trainee turnovers at the beginning of the academic year. The influx of new gynecology and surgery residents into hospitals in this setting may be associated with poorer surgical outcomes, known as the July effect. We sought to systematically study hysterectomy outcomes in the state of Maryland during the 3-month period July through September as compared to all other months of the academic year, in order to assess for the presence of a July effect in hysterectomy surgery. This is a retrospective study of the Maryland Health Services Cost Review Commission Database from July 2012 through September 2015 focused on women undergoing hysterectomies for benign or malignant disease, either by obstetricians and gynecologists or gynecologic oncologists, during July through September vs October through June. Multivariable logistic regressions accounted for clustering by hospitals and adjusted for several cofactors. The primary outcome includes at least 1 of 11 major perioperative in-hospital complications; the secondary outcomes were extended postoperative length of stay (defined as >2 days) and 30-day inpatient readmission rates. We identified 6311 hysterectomies (78.2% benign) performed by 424 surgeons at 20 academic hospitals. Patients were primarily white (42.8%), 45-64 years old (54.4%), and had private insurance (66.3%). The unadjusted rate of in-hospital complications was 16.8%, extended length of stay was 30.3%, and 30-day readmissions was 6.6%. After adjustment, patients undergoing hysterectomies during July through September did not have more adverse outcomes relative to those undergoing surgery at other times of the year: complications (adjusted odds ratio, 0.87; 95% confidence interval, 0.75-1.01), length of stay >2 days (adjusted odds ratio, 1.03; 95% confidence interval, 0.90-1.19), and 30-day readmissions (adjusted odds ratio, 0.99; 95% confidence interval, 0.80-1.23). Sensitivity analyses assessing individual complications, hysterectomy outcomes at nonacademic hospitals, and benign vs malignant indications for hysterectomies yielded similar findings. Women in Maryland undergoing hysterectomy surgery at academic hospitals during July through September of the academic year did not experience worse outcomes relative to women having surgery in other months. Additional studies are necessary to further assess the possibility of a July effect in hysterectomy on a national basis. Institutions should continue to provide effective surgical training environments for new interns and residents transitioning to more senior roles, while maintaining optimal patient safety.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes.

Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. Prognostic and epidemiological, level IV.

A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures

Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10days) and in-hospital mortality. Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P≤0.024), diabetics ($2,058 [837-3,279]; P<0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P<0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P<0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P<0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P<0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after2014. This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.

Trauma transitional care coordination: A mature system at work.

We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination (TTCC) Program in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations. TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. The TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission database to collect data on statewide unplanned 30-day readmissions. Four hundred seventy-five patients were enrolled in the TTCC program from January 2014 to September 2016. Only 10.5% (n = 50) of TTCC enrollees were privately insured, 54.5% had Medicaid (n = 259), and 13.5% had Medicare (n = 64). Seventy-three percent had Health Services Cost Review Commission severity of injury ratings of 3 or 4 (maximum severity of injury = 4). The most common All Patient Refined Diagnosis Related Groups for participants were: lower-extremity procedures (n = 67, 14%); extensive abdominal/thoracic procedures (n = 40, 8.4%); musculoskeletal procedures (n = 37, 7.8%); complicated tracheostomy and upper extremity procedures (n = 29 each, 6.1%); infectious disease complications (n = 14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n = 13 each, 2.7%). The TTCC participants with lower-extremity injury, complicated tracheostomy, and bowel procedures had 6-point reduction (10% vs. 16%, p = 0.05), 11-point reduction (13% vs. 24%, p = 0.05), and 16-point reduction (11% vs. 27%, p = 0.05) in 30-day readmission rates, respectively, compared to those without TTCC. Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower-extremity injury, complicated tracheostomy and bowel procedures. This represents over one million-dollar savings for the hospital per year through quality-based reimbursement. Therapeutic/care management, level III.

Global budgets in Maryland: early evidence on revenues, expenses, and margins in regulated and unregulated services.

Maryland implemented one of the most aggressive payment innovations the nation has seen in several decades when it introduced global budgets in all its acute care hospitals in 2014. Prior to this, a pilot program, total patient revenue (TPR), was established for 8 rural hospitals in 2010. Using financial hospital report data from the Health Services Cost Review Commission from 2007 to 2013, we examined the hospitals' financial results including revenue, costs, and profit/loss margins to explore the impact of the adoption of the TPR pilot global budget program relative to the remaining hospitals in the state. We analyze financial results for both regulated (included in the global budget and subject to rate-setting) and unregulated services in order to capture a holistic image of the hospitals' actual revenue, cost and margin structures. Common size and difference-in-differences analyses of the data suggest that regulated profit ratios for treatment hospitals increased (from 5% in 2007 to 8% in 2013) and regulated expense-to-gross patient revenue ratios decreased (75% in 2007 and 68% in 2013) relative to the controls. Simultaneously, the profit margins for treatment hospitals' unregulated services decreased (- 12% in 2007 and - 17% in 2013), which reduced the overall margin significantly. This analysis therefore indicates cost shifting and less profit gain from the program than identified by solely focusing on the regulated margins.

Venous Thromboembolism Quality Measures Fail to Accurately Measure Quality.

Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients' risk for VTE and prescribe therapy appropriate for each patient's risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.

Surgeon variation in operating times and charges for emergency general surgery

BackgroundPatients and hospitals face significant financial burdens from emergency general surgeries (EGSs), which have been termed a public health crisis in the United States. We evaluated hospitalization charges, operating charges, and variations in operating time by surgeon volume for three common EGS procedures. MethodsUsing Maryland's Health Services Cost Review Commission database, we performed a retrospective study of laparoscopic appendectomies, laparoscopic cholecystectomies, and open bowel resections performed by general surgeons among adult patients from July 2012 to September 2014. We compared operating charges to total hospitalization charges and quantified variations in operating time for each procedure. We then divided patients into quartiles based on their surgeon's procedure-specific case volume and used hierarchical linear regressions to calculate differences in both operating time and charges between quartiles. ResultsWe identified 3194 appendectomies, 4143 cholecystectomies, and 1478 bowel resections. Operating charges accounted for one-quarter (26.9%) of total hospitalization charges and widespread variation existed in operating time (appendectomies: median 79 min [interquartile range 66-100 min], cholecystectomies: 96 min [76-125 min], bowel resections: 155 min [117-209 min]). After adjustment, low-volume surgeons relative to high-volume surgeons did not operate statistically longer for appendectomies (+1%, 95% confidence interval [CI]: −2% to 5%) but operated +16% (95% CI: 12%-20%) longer for cholecystectomies (+14 min) and +40% (95% CI: 30%-50%) longer for bowel resections (+59 min). Adjusted median operating charges from low-volume surgeons relative to high-volume surgeons were $554 (26.7%), $621 (22.0%), and $1801 (47.0%) greater for appendectomies, cholecystectomies, and bowel resections, respectively. ConclusionsOperating charges contributed substantially to total EGS hospitalization charges, where low-volume surgeons operated longer and had higher operative charges relative to high-volume surgeons. Reducing variations in operating times and charges represents an opportunity to alleviate the financial burden from EGS procedures.

Emergency pediatric surgery: Comparing the economic burden in specialized versus nonspecialized children's centers

The American College of Surgeons has developed a verification program for children's surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized children's centers would utilize more resources. We performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009 to 2013. We assessed total charge, length of stay (LOS), and charge per day for all inpatients with an emergency pediatric surgery diagnosis, controlling for severity of illness (SOI). Using published resources, we assigned theoretical level designations to each hospital. Two hospitals would qualify as Level 1 hospitals, with 4593 total emergency pediatric surgery admissions (38.5%) over the five-year study period. Charges were significantly higher for children treated at Level I hospitals (all P<0.0001). Across all SOI, children at Level I hospitals had significantly longer LOS (all P<0.0001). Hospitals defined as Level II and Level III provided the majority of care and were able to do so with shorter hospitalizations and lower charges, regardless of SOI. As care shifts towards specialized centers, this charge differential may have significant impact on future health care costs. Level III Cost Effectiveness Study.

Maryland's All-Payer Health Care System

The state of Maryland, in collaboration with the Centers for Medicare & Medicaid Services, developed the first all-payer system model in the Unites States in 1971 and 35 years later in response to financial pressures undertook to modernize this program. The focus of the modernized program was to improve overall per-capita expenditure, quality of care, and the outcome of Marylanders' health. The financial status of Maryland hospitals was declining because of the rate setting of the Health Services Cost Review Commission while hospital admission rates and spending were increasing. This study showed positive change in moving Maryland health care delivery model in hospitals from volume-driven care to value-driven coordinated care. Maryland hospitals have changed their mind-sets to achieve the Triple Aim of cost reduction, health improvement, and quality-of-care improvement. The modernized model does require hospitals and business individuals to change their approach to be accountable in providing health care to all citizens, as well as trying to solve chronic social problems such as poverty and unequal access to health care.

Invited commentary

Dr Harris and colleagues argue that services for vascular acute care surgery (VACS) should be established in tertiary referral centers for nonelective care. Further, they speculate that additional training and advanced certification of vascular surgeons and VACS program accreditation may be required in the future. Their analyses likely overestimate the burden of emergency vascular care. The Health Services Cost Review Commission inpatient data set they reviewed provided minimal information about the nature of patients' vascular conditions and procedures. As expected, urgent or emergency hospitalization was associated with greater resource utilization and poorer outcomes. The analysis, however, could not determine whether vascular disease or injury was the reason for admission or whether vascular procedures were needed during hospitalization to address complications or comorbidities. Vascular diagnoses were not specified, nor was the urgency of procedures performed. Many nonelective hospital admissions for vascular diagnoses are not true emergencies. Emergency Department cases may become “acute” because of lack of insurance, inadequate primary care, or because of a primary care provider's choice to first send the patient to the Emergency Department for management. All board-certified vascular surgeons, regardless of their training pathway, should be competent to handle most nonelective problems, including thromboembolectomy, vascular access procedures, angiography, inferior vena cava filter placements, amputations, treatment of pseudoaneurysms, and the like. These procedures should not require transfer to an acute vascular care center. Complex care is already regionalized to larger centers. There are 5564 United States hospitals,1American Hospital Association AHA Hospital Statistics. Fast facts on US hospitals.http://www.aha.org/research/rc/stat-studies/fast-facts.shtmlGoogle Scholar but only 3767 vascular surgeons.2American Board of Surgery Statistics and pass rates.http://www.absurgery.org/default.jsp?statsummaryGoogle Scholar The need for triage and transfer should be considered the norm. Although there can be problems with access to care and timeliness of transfer, it is unlikely that establishing VACS teams at regional centers will be the answer. Interestingly, our group at a medium-sized academic medical center (a level 1 trauma center) instituted an acute vascular surgery care service. We found the change unhelpful. After a 1-year trial, we reverted to our traditional coverage model. We still handle ruptured aneurysms, acute limb ischemia, and other complex vascular problems, but without a service dedicated to acute problems. Implementation a VACS service may make sense where most of the work is urgent or an emergency. That does not mean it is right for most programs. Management of clinical services needs to be based on referral patterns, local resources, and institutional priorities, not national directives. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Defining the burden, scope, and future of vascular acute care surgeryJournal of Vascular SurgeryVol. 66Issue 5PreviewThe paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. Full-Text PDF Open Archive

A spatial analysis of race, local health-promoting resources and preventable hospitalizations

IntroductionPreventable hospitalizations (PHs) for chronic conditions could have been avoided if treated with primary healthcare. PH rates are higher among African Americans, and in areas with less healthcare. Little is known about the effects of non-healthcare local health-promoting resources (LHPRs). The objective of this study is to determine associations between LHPRs and chronic PH rates in Maryland, and to assess spatial clustering of areas with high PH rates. MethodsHospitalizations in 2010 were obtained from the Maryland Health Services Cost Review Commission by zip code of residence. Negative binomial regressions were used to determine associations between PH rates and LHPRs by race. Clusters of zip codes with high PH rates were assessed using the spatial Scan Statistic. ResultsPH rates were associated with family practitioners (IRR=0.98, 95% CI=0.97–0.99), physicians' assistants (IRR=0.98, 95% CI=0.96–0.99), internists (IRR=1.02, 95% CI=1.01–1.03), teaching hospitals (IRR=1.21, 95% CI=1.04–1.40), and local health departments (IRR=1.19, 95% CI=1.03–1.37). No LHPRs were associated with PHs among whites, but African American PH rates were associated with family practitioners (IRR=0.97, 95% CI=0.94–0.99), nurse practitioners (IRR=1.03, 95% CI=1.01–1.06), teaching hospitals (IRR=1.37, 95% CI=1.08–1.75) and gyms/recreational centers (IRR=0.85, 95% CI=0.73–0.99). Clusters of areas with high PH rates varied by race. African American PH clusters had fewer family practitioners and more federally qualified health centers and teaching hospitals. ConclusionsPublic health practitioners should look to LHPRs beyond physician supply or public clinics to address PHs, particularly among African Americans. Specific LHPRs could be used to target African American PH rates and clusters.

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes

Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes. Using Maryland's Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons. We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures. We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments

A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did notsignificantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than theiruninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

2: Patient, surgeon, and hospital disparities associated with hysterectomy approach and perioperative complications

Hysterectomies are among one of the most common major surgical procedures performed in women. However, little is known regarding contemporary U.S. hysterectomy trends for women with benign disease with respect to both operative technique and perioperative complications. We sought to document these trends and to determine the association between these two factors with patient, surgeon, and hospital characteristics. Hysterectomies performed for benign indications by generalist gynecologists from 2012-2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We included both open hysterectomies and those performed by minimally invasive surgery (MIS). Perioperative complications were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeon hysterectomy volume was analyzed by quartiles (0-5 = very low, 6-10 = low, 11-20 = medium, and 21+ cases = high volume). We utilized negative binomial regression and logistic regression to identify patient, surgeon, and hospital characteristics associated with MIS utilization and perioperative complications, respectively. A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; the remaining (38.6%) underwent a MIS procedure (25.1% robotic, 46.6% laparoscopic, and 28.3% vaginal). Most surgeons (68.2%) performed 10 or fewer hysterectomies during the 2+ year study period. Factors associated with a lower likelihood of undergoing MIS were older patient age (ref: 45-64 years; 20-44: OR = 1.17, 95% CI = 1.06-1.28), black race (ref: white; OR = 0.72, 95% CI = 0.65-0.80), Hispanic ethnicity (OR = 0.62, 95% CI = 0.48-0.79), smaller hospital size (ref: large; small: OR = 0.25, 95% CI = 0.15-0.44; medium: OR = 0.83, 95% CI = 0.75-0.91), and lower surgeon volume (ref: high; medium: OR = 0.87, 95% CI = 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of MIS hysterectomies (P < 0.0001). While MIS hysterectomy was associated with fewer complications (OR = 0.22, 95% CI = 0.17-0.27), patient payer, including Medicare (ref: private; OR = 1.88, 95% CI = 1.34-2.64), Medicaid (OR = 1.70, 95% CI = 1.34-2.11) and self-pay status (OR = 2.49, 95% CI = 1.47-4.27), and low surgeon hysterectomy volume (ref: high; very low: OR = 1.91, 95% CI = 1.34-2.73; low: OR = 1.73, 95% CI = 1.22-2.47) were associated with perioperative complications. Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients, lower volume surgeons, and smaller hospitals were associated with open hysterectomy. Patient race and payer and lower surgeon volume were also associated with perioperative complications. Hysterectomies performed by high volume surgeons, and especially those with expertise in minimally invasive techniques, may represent an opportunity to reduce adverse events.

Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications

Hysterectomy is among the most common major surgical procedures performed in women. Approximately 450,000 hysterectomy procedures are performed each year in the United States for benign indications. However, little is known regarding contemporary UShysterectomy trends for women with benign disease with respect tooperative technique and perioperative complications, and the association between these 2 factors with patient, surgeon, and hospital characteristics. We sought to describe contemporary hysterectomy trends and explore associations between patient, surgeon, and hospital characteristics with surgical approach and perioperative complications. Hysterectomies performed for benign indications by general gynecologists from July 2012 through September 2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We excluded hysterectomies performed by gynecologic oncologists, reproductive endocrinologists, and female pelvic medicine and reconstructive surgeons. We included both open hysterectomies and those performed by minimally invasive surgery, which included vaginal hysterectomies. Perioperative complications were defined using the Agency for Healthcare Research and Qualitypatient safety indicators. Surgeon hysterectomy volume during the 2-year study period was analyzed (0-5 cases annually= very low, 6-10= low, 11-20= medium, and ≥21= high). We utilized logistic regression and negative binomial regression to identify patient, surgeon, and hospital characteristics associated with minimally invasive surgery utilization and perioperative complications, respectively. A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; 38.5% underwent a minimally invasive surgery procedure (25.1% robotic, 46.6% laparoscopic, 28.3% vaginal). Most surgeons (68.2%) were very low- or low-volume surgeons. Factors associated with a lower likelihood of undergoing minimally invasive surgery included older patient age (reference 45-64 years; 20-44 years: adjusted odds ratio, 1.16; 95% confidence interval, 1.05-1.28), black race (reference white; adjusted odds ratio, 0.70; 95% confidence interval, 0.63-0.78), Hispanic ethnicity (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80), smaller hospital (reference large; small: adjusted odds ratio, 0.26; 95% confidence interval, 0.15-0.45; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.96), medium hospital hysterectomy volume (reference ≥200 hysterectomies; 100-200: adjusted odds ratio, 0.78; 95% confidence interval, 0.71-0.87), and medium vs high surgeon volume (reference high; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of minimally invasive hysterectomies (P < .0001). Minimally invasive hysterectomy (adjusted odds ratio, 0.22; 95% confidence interval, 0.17-0.27) and large hysterectomy volume hospitals (reference ≥200 hysterectomies; 1-100: adjusted odds ratio, 2.26; 95% confidence interval, 1.60-3.20; 101-200: adjusted odds ratio, 1.63; 95% confidence interval, 1.23-2.16) were associated with fewer complications, while patient payer, including Medicare (reference private; adjusted oddsratio, 1.86; 95% confidence interval, 1.33-2.61), Medicaid (adjusted odds ratio, 1.63; 95% confidence interval, 1.30-2.04), and self-pay status (adjusted odds ratio, 2.41; 95% confidence interval, 1.40-4.12), and very-low and low surgeon hysterectomy volume (reference ≥21 cases; 1-5 cases: adjusted odds ratio, 1.73; 95% confidence interval, 1.22-2.47; 6-10 cases: adjusted odds ratio, 1.60; 95% confidence interval, 1.11-2.23) were associated with perioperative complications. Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients and smaller hospitals are associated with open hysterectomy. Patient race and payer status, hysterectomy approach, and surgeon volume were associated with perioperative complications. Hysterectomies performed for benign indications by high-volume surgeons or by minimally invasive techniques may represent an opportunity to reduce preventable harm.