HealthSystem Consortium Clinical Database Research Articles

Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions

Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge was associated with 30-day readmissions among a cohort of hospitalizations in a single health care system. From January 1, 2009, to August 31, 2011, there were 152,757 eligible hospitalizations within a single health care system. The endpoint was any hospitalization within 30 days of discharge. The University HealthSystem Consortium's clinical database was used for demographics and comorbidities; hemoglobin values are from the hospitals' electronic medical records, and readmission status was obtained from the University HealthSystem Consortium administrative data systems. Mild anemia was defined as hemoglobin of greater than 11 to less than 12 g/dl in women and greater than 11 to less than 13 g/dl in men; moderate, greater than 9 to less than or equal to 11 g/dl; and severe, less than or equal to 9 g/dl. Logistic regression was used to assess the association of anemia and 30-day readmissions adjusted for demographics, comorbidity, and hospitalization type. Among 152,757 hospitalizations, 72% of patients were discharged with anemia: 31,903 (21%), mild; 52,971 (35%), moderate; and 25,522 (17%), severe. Discharge anemia was associated with severity-dependent increased odds for 30-day hospital readmission compared with those without anemia: for mild anemia, 1.74 (1.65-1.82); moderate anemia, 2.76 (2.64-2.89); and severe anemia, 3.47 (3.30-3.65), P < 0.001. Anemia at discharge is associated with a severity-dependent increased risk for 30-day readmission. A strategy focusing on anemia treatment care paths during index hospitalization offers an opportunity to influence subsequent readmissions.

The University Healthsystem Consortium clinical database: An emerging resource in colorectal surgery research

In the era of big data, many options exist for analysis of health care related outcomes. The University HealthSystem Consortium Clinical Database/Resource Manager (UHC CDB/RM) represents one such source. With over 400 hospitals participating, UHC comprises >95% of academic centers and their affiliates. Primarily used as an avenue for hospitals to meet requirements in quality assurance activities, it also makes available patient-level data on over 30 million inpatient encounters. In recent years, UHC has been increasingly used to assess quality and cost outcomes for surgical patients, many of which have been specific to colorectal procedures. Though it has limitations, it provides a useful source of data to assess quality and cost outcomes, especially at a time when these metrics are used to gauge surgeons and hospitals, as well as determine reimbursements for surgical procedures.

Interhospital transfer patients discharged by academic hospitalists and general internists: Characteristics and outcomes.

Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. Retrospective cohort study. A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). In this large national sample, IHT status is independently associated with inpatient mortality.

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement. Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α=0.05). Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18years) underwent PEH surgery, 84.7% were performed laparoscopically and 15.3% open. 24.6% of cases were classified urgent/emergent upon admission, and almost 70% of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30% of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9% LHR vs. 26.3% OHR). Almost 90% of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement. We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.

Utilization and outcome of laparoscopic versus robotic general and bariatric surgical procedures at Academic Medical Centers.

Robotic-assisted general and bariatric surgery is gaining popularity among surgeons. The aim of this study was to analyze the utilization and outcome of laparoscopic versus robotic-assisted laparoscopic techniques for common elective general and bariatric surgical procedures performed at Academic Medical Centers. We analyzed data from University HealthSystem Consortium clinical database from October 2010 to February 2014 for all patients who underwent laparoscopic versus robotic techniques for eight common elective general and bariatric surgical procedures: gastric bypass, sleeve gastrectomy, gastric band, antireflux surgery, Heller myotomy (HM), cholecystectomy (LC), colectomy, rectal resection (RR). Utilization and outcome measures including demographics, in-hospital mortality, major complications, 30-day readmission, length of stay (LOS), and costs were compared between techniques. 96,694 laparoscopic and robotic procedures were analyzed. Utilization of the robotic approach was the highest for RR (21.4%), followed by HM (9.1%). There was no significant difference in in-hospital mortality or major complications between laparoscopic versus robotic techniques for all procedures. Only two procedures had improved outcome associated with the robotic approach: robotic HM and robotic LC had a shorter LOS compared to the laparoscopic approach (2.8 ± 3.6 vs. 2.3 ± 2.1; respectively, p < 0.05 for HM and 2.9 ± 2.4 vs. 2.3 ± 1.7; respectively, p < 0.05 for LC). Costs were significantly higher (21%) in the robotic group for all procedures. A subset analysis of patients with minor/moderate severity of illness showed similar results. This national analysis of academic centers showed a low utilization of robotic-assisted laparoscopic elective general and bariatric surgical procedures with the highest utilization for rectal resection. Compared to conventional laparoscopy, there were no observed clinical benefits associated with the robotic approach, but there was a consistently higher cost.

Body Mass Index is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m(2) or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m(2) or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m(2) or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Validation of the University HealthSystem Consortium Clinical Database: Concordance and Discordance with Patient-Level Institutional Data

Validation of the University HealthSystem Consortium Clinical Database: Concordance and Discordance with Patient-Level Institutional Data

Separate may not be equal: A preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers

ObjectivesElectronic Medical Records (EMR) have the potential to improve the coordination of healthcare in this country, yet the field of psychiatry has lagged behind other medical disciplines in its adoption of EMR. MethodsPsychiatrists at 18 of the top US hospitals completed an electronic survey detailing whether their psychiatric records were stored electronically and accessible to non-psychiatric physicians. Electronic hospital records and accessibility statuses were correlated with patient care outcomes obtained from the University Health System Consortium Clinical Database available for 13 of the 18 top US hospitals. Results44% of hospitals surveyed maintained most or all of their psychiatric records electronically and 28% made psychiatric records accessible to non-psychiatric physicians; only 22% did both. Compared with hospitals where psychiatric records were not stored electronically, the average 7-day readmission rate of psychiatric patients was significantly lower at hospitals with psychiatric EMR (5.1% vs. 7.0%, p=.040). Similarly, the 14 and 30-day readmission rates at hospitals where psychiatric records were accessible to non-psychiatric physicians were lower than those of their counterparts with non-accessible records (5.8% vs. 9.5%, p=.019, 8.6% vs. 13.6%, p=.013, respectively). The 7, 14, and 30-day readmission rates were significantly lower in hospitals where psychiatric records were both stored electronically and made accessible than at hospitals where records were either not electronic or not accessible (4% vs 6.6%, 5.8% vs 9.1%, 8.9 vs 13%, respectively, all with p=0.045). ConclusionsHaving psychiatric EMR that were accessible to non-psychiatric physicians correlated with improved clinical care as measured by lower readmission rates specific for psychiatric patients.

Outcome of laparoscopic adjustable gastric banding and prevalence of band revision and explantation at academic centers: 2007–2009

BackgroundLaparoscopic adjustable gastric banding is gaining in popularity in the United States. Our objective was to examine the outcomes of laparoscopic adjustable gastric banding and the prevalence of band revision and explantation at academic medical centers. MethodsUsing the “International Classification of Diseases, 9th revision,” diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding procedures performed from 2006 to 2009. The outcome measures included demographics, length of hospital stay, perioperative morbidity, mortality, and the prevalence of band revision and explantation. ResultsA total of 10,151 laparoscopic gastric banding procedures were performed from January 2007 to December 2009. The mean length of stay was 1.2 days. The perioperative morbidity rate was 3.0%, and the in-hospital mortality rate was .03%. The prevalence of band revision was .76% and of band explantation was .87%. Compared with the outcome of primary gastric banding, gastric band revision or explantation was associated with a longer length of hospital stay, greater perioperative morbidity, and greater cost. ConclusionWithin the context of the 3-year period of analysis, laparoscopic gastric banding was associated with low perioperative morbidity and mortality and a low prevalence of band revision and explantation.

Outcomes After Pediatric Ureteral Reimplantation: A Population Based Analysis

Pediatric urology literature is often biased toward single, high volume institutions. We determined the impact of patient, surgeon and hospital characteristics on immediate outcomes for children undergoing ureteral reimplantation. We queried the University Health-System Consortium Clinical Data Base to identify a pediatric population who underwent ureteroneocystostomy between 2004 and 2009. We measured the association of the outcome variables length of stay, number of days in the intensive care unit and complication rates on the independent variables of age, gender, race, insurance status, year of surgery, and surgeon and hospital characteristics. The data were analyzed using multiple logistic, Poisson and Poisson hurdle model regression analyses incorporating random effects for surgeon and hospital. We identified 5,668 subjects who underwent ureteroneocystostomy. Compared with patients treated by high volume providers, those treated by low volume surgeons (less than 13 cases per year) had a longer length of stay (47%), higher odds of intensive care unit admission (OR 8.1), longer intensive care unit stays (103%) and higher rate of surgical related complications (162%). Other independent variables of male gender, nonwhite race and prior comorbidities were independently associated with longer length of stay, higher intensive care unit admissions and higher risk of complications. Surgeon volume, not hospital volume, is an important and consistent predictor of length of stay, intensive care unit admissions, intensive care unit days and complication rate after ureteroneocystostomy. These findings posit that the short length of stay, low intensive care unit admission rate and low complication rate reported in the literature may not be generalizable, but rather limited to higher volume surgeons.

Immediate surgical outcomes for radical prostatectomy in the University HealthSystem Consortium Clinical Data Base: the impact of hospital case volume, hospital size and geographical region on 48 000 patients

To determine the impact of hospital variables on immediate surgical outcomes for patients treated with radical prostatectomy (RP) in academic centres. The University HealthSystem Consortium (UHC) Clinical Data Base was queried for data corresponding to patients who had RP at one of 130 academic medical centres nationwide between 2003 and the second quarter of 2007 (48,086). RP case volume (1-99, 100-499 and >500), total discharges (1-49,999, 50,000-99,999 >100,000), and geographical region (five categories) were determined and categorized for each academic centre. Analysis of variance and the Tukey statistic were used to assess the results. Length of stay (LOS), intensive care unit (ICU) rate, complication rate (CR) and in-hospital mortality (IHM) were analysed. Case volume was a significant predictor of LOS, ICU and CR. The mean LOS was 3.77, 2.65 and 2.09 days, respectively, for centres from three tiers of lowest to highest case volumes (P < 0.001). ICU rates for the three tiers were 18.57, 3.61, and 1.30 (P < 0.001); CRs were 15.93, 8.79 and 5.76 (P < 0.001). Tukey analysis showed a 'ceiling' effect for ICU and CRs; there were no differences between the two higher case-volume groups. IHM was not significantly different between groups stratified by case volume. Stratification by total discharges showed differences in ICU rates only (P = 0.003). Stratification by geographical region showed no differences in outcome. RP case volume was an important variable in predicting three of the four outcome variables. CRs and ICU rates showed a 'ceiling effect' suggesting that an unknown 'critical volume' of cases portends improved surgical outcomes.

Assessing Surgical Quality Using Administrative and Clinical Data Sets: A Direct Comparison of the University HealthSystem Consortium Clinical Database and the National Surgical Quality Improvement Program Data Set

The use of "clinical" versus "administrative" data sets for health care quality assessment continues to be debated. This study directly compares the University HealthSystem Consortium Clinical Database (UHC CDB) and the National Surgical Quality Improvement Program (NSQIP) in terms of their assessment of complications and death for 26 322 surgery patients using analyses of variance, correlation, and multivariable logistic regression. The NSQIP had more variables with significant correlation with outcomes. The NSQIP was better at predicting death (c-index 0.94 vs 0.90, P < .05) and complications (c-index 0.78 vs 0.76, P = .07), especially for higher risk patients. The UHC CDB missed and misclassified several major complications. The data sets are similar in their explanatory power relative to outcomes, but the clinical data set is better, particularly at identifying higher risk patients and specific complications. It should prove more useful for initiating and monitoring clinical process improvements because of more clinically relevant variables.

National trends in use and outcome of laparoscopic adjustable gastric banding

Background Laparoscopic adjustable gastric banding is gaining popularity in the United States. Our objective was to examine the use and outcomes of laparoscopic adjustable gastric banding at academic medical centers. Methods Using the “International Classification of Diseases, Ninth Revision” diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding and gastric bypass procedures performed from 2004 to 2007. Quartile trends in the use of all procedures were determined, and a comparison of in-hospital morbidity and mortality between laparoscopic adjustable gastric banding and laparoscopic gastric bypass was performed. Results A total of 31,333 bariatric surgery procedures were performed from 2004 to 2007. During this period, the use of laparoscopic adjustable gastric banding and gastric bypass procedures increased from 7% to 23% and 53% to 66%, respectively. A concurrent decrease occurred in the use of open gastric bypass procedures from 40% to 11%. Compared with laparoscopic gastric bypass, laparoscopic adjustable gastric banding was associated with a significantly shorter length of stay (1.3 versus 2.7 d, P <.01), lower morbidity (2.8% versus 7.5%, P <.01), lower 30-day readmission rate (.7% versus 2.5%, P <.01), lower in-hospital mortality (.02% versus .08%, P <.01), and lower hospital cost ($8689 versus 14,386, P <.01). Conclusion From 2004 to 2007, significant growth occurred in the number of laparoscopic adjustable gastric banding (+329%) and laparoscopic gastric bypass (+125%) procedures, with a precipitous decrease in the number of open gastric bypass (−73%) procedures. The increasing popularity of the laparoscopic adjustable gastric band procedure could in part be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass.

Laparoscopic Surgery Is Associated With a Lower Incidence of Venous Thromboembolism Compared With Open Surgery

Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.

Outcomes of Right and Left Colectomy at Academic Centers

Few studies have compared outcomes of right colectomy (RC) and left colectomy (LC) with respect to both benign and malignant disease. The objective of this study was to compare outcomes of RC versus LC for benign and malignant disease using a national administrative database of academic medical centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, data was obtained from the University HealthSystem Consortium Clinical Data Base for patients that underwent RC and LC for benign and malignant disease between 2002 and 2006. The main outcomes compared were demographics, length of hospital stay, observed to expected in-hospital mortality, complications, 30-day readmission, and mean cost. There were a total of 27,483 patients; 12,971 patients (47.2%) underwent RC. Compared with LC for benign disease, RC was associated with a shorter length of stay, lower overall complications, lower wound infections, lower 30-day readmissions, and lower cost. Compared with LC for malignant disease, RC was associated with lower overall complications, lower wound infections, and lower cost. In this analysis of academic centers, RC was associated with a lower length of stay, lower morbidity, and lower cost when compared with LC for benign and malignant disease.

Association of Procedure Volume With Radical Cystectomy Outcomes in a Nationwide Database

Studies of national databases yield important information about expected outcomes after radical cystectomy and factors that influence patient morbidity and mortality. We examined the hospital characteristics associated with outcomes after radical cystectomy in a cohort study using results from a single, high volume academic institution as well as a nationwide data set of academic institutions. We obtained data from the University HealthSystem Consortium Clinical Database on 6,728 patients nationwide who underwent radical cystectomy for bladder cancer between 2002 and 2005 as well as on 421 who underwent cystectomy at our institution during this period. Outcomes were compared by hospital characteristics (geographic location, total hospital discharges and procedure volume). The outcome measures analyzed were length of hospital stay, the complication rate and in hospital mortality. The overall complication rate at our institution was 32.07% with an in hospital mortality rate of 0.95% and an average length of stay of 7.05 days. The overall complication rate in the University HealthSystem Consortium data set was 37.16% with an in hospital mortality rate of 1.47% and an average length of stay of 10.98 days. Institutions with higher cystectomy volumes had significantly better outcomes than institutions with lower procedure volumes. The mortality rate at institutions with greater than 50 cystectomies per year was 0.54% compared to 2.70% at institutions with 10 or fewer per year (p <0.0005). Outcomes varied only minimally with total hospital discharges or geographic region. Even among academic medical centers hospitals with a higher volume of cystectomies in 2002 to 2005 were associated with improved outcomes, including decreased mortality, shorter length of stay and lower rehospitalization rates. These data may provide a framework for self-assessment and help establish criteria for performance evaluation.

Outcomes of Bariatric Surgery in the Elderly

The Medicare Coverage Advisory Committee recently concluded that evidence supports the safety and effectiveness of bariatric surgery in the general adult population. However, more information is needed on the role of bariatric surgery in the elderly. The aim of this study was to examine the outcome of bariatric surgery in the elderly performed at academic centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all elderly (>60 years) and nonelderly (19-60 years) patients who underwent bariatric surgery for the treatment of morbid obesity between 1999 and 2005. Outcome measures, including patient characteristics, length of stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality, were compared between groups. Bariatric surgery in the elderly represents 2.7 per cent (n = 1,339) of all bariatric operations being performed at academic centers. Of the 99 University HealthSystem Consortium centers performing bariatric surgery, 78 centers (79%) perform bariatric surgery in the elderly. Compared with nonelderly patients, elderly patients who underwent bariatric surgery had more comorbidities, longer lengths of stay (4.9 days vs 3.8 days, P < 0.01), more overall complications (18.9% vs 10.9%, P < 0.01), pulmonary complications (4.3% vs 2.3%, P < 0.01), hemorrhagic complications (2.5% vs 1.5%, P < 0.01), and wound complications (1.7% vs 1.0%). The in-hospital mortality rate was also higher in the elderly group (0.7% vs 0.3%, P = 0.03). When risk adjusted, the observed-to-expected mortality ratio for the elderly group was 0.9. In a subset of elderly patients with a pre-existing cardiac condition (n = 236), the in-hospital mortality was 4.7 per cent. Bariatric surgery in the elderly represents only a small fraction of the number of bariatric operations performed at academic centers. Although the morbidity and mortality is higher in the elderly, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality.

Trends in utilization and outcomes of laparoscopic versus open appendectomy

Background Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. Methods Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. Results Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 ( P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups ($6,242 vs $6,260). Conclusions Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

The relationship between hospital volume and outcome in bariatric surgery at academic medical centers.

To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.

An Analysis of the Relationship Between the Utilization of Physical Therapy Services and Outcomes of Care for Patients After Total Hip Arthroplasty

The effect of physical therapy intervention on the outcomes of care for patients treated in acute care hospitals has not been widely studied. This study examined the relationship between physical therapy utilization and outcomes of care for patients following total hip arthroplasty. The sample consisted of 7,495 patients treated in US academic health center hospitals in 1996 who survived their inpatient stay and received physical therapy interventions. The primary data source was the University HealthSystem Consortium Clinical Data Base. Physical therapy use was assessed by examining physical therapy charges. Outcomes of care were assessed in terms of the total cost of care (ie, whether the care was more costly or less costly than expected, taking into account patient characteristics) and in terms of discharge destination (ie, whether the patient was discharged home or elsewhere). Regression analyses were conducted to examine the relationship between physical therapy use and outcomes. Physical therapy intervention was directly related to a total cost of care that was less than expected and to an increased probability of discharge home. The results of this study provide preliminary evidence to support the use of physical therapy intervention in the acute care of patients following total hip arthroplasty and indicate the need for further study of this topic.