Hospital Acquisition Research Articles

Relationship between Fungal Colonisation of the Respiratory Tract in Lung Transplant Recipients and Fungal Contamination of the Hospital Environment.

BackgroundAspergillus colonisation is frequently reported after lung transplantation. The question of whether aspergillus colonisation is related to the hospital environment is crucial to prevention.MethodTo elucidate this question, a prospective study of aspergillus colonisation after lung transplantation, along with a mycological survey of the patient environment, was performed.ResultsForty-four consecutive patients were included from the day of lung transplantation and then examined weekly for aspergillus colonisation until hospital discharge. Environmental fungal contamination of each patient was followed weekly via air and surface sampling. Twelve patients (27%) had transient aspergillus colonisation, occurring 1–13 weeks after lung transplantation, without associated manifestation of aspergillosis. Responsible Aspergillus species were A. fumigatus (6), A. niger (3), A. sydowii (1), A. calidoustus (1) and Aspergillus sp. (1). In the environment, contamination by Penicillium and Aspergillus was predominant. Multivariate analysis showed a significant association between occurrence of aspergillus colonisation and fungal contamination of the patient’s room, either by Aspergillus spp. in the air or by A.fumigatus on the floor. Related clinical and environmental isolates were genotyped in 9 cases of aspergillus colonisation. For A. fumigatus (4 cases), two identical microsatellite profiles were found between clinical and environmental isolates collected on distant dates or locations. For other Aspergillus species, isolates were different in 2 cases; in 3 cases of aspergillus colonisation by A. sydowii, A. niger and A. calidoustus, similarity between clinical and environmental internal transcribed spacer and tubulin sequences was >99%.ConclusionTaken together, these results support the hypothesis of environmental risk of hospital acquisition of aspergillus colonisation in lung transplant recipients.

Hospital Acquisition of Physician Groups: On the Road to Value-Based or Higher-Priced Care?

An important goal of the Affordable Care Act is to transform the US health care system from one characterized by high costs, poor quality, and fragmented care to one focused on comprehensive, coordinated, and efficient care.

Rural Hospital Mergers and Acquisitions: Which Hospitals Are Being Acquired and How Are They Performing Afterward?

The number of stand-alone rural hospitals has been shrinking as larger health systems target these hospitals for mergers and acquisitions (M and As). However, little research has focused specifically on rural hospital M and A transactions. Using data from Irving Levin Associates' Healthcare M and A Report and Medicare Cost Reports from 2005 to 2012, we examined two research questions: (1) What were the characteristics of rural hospitals that merged or were acquired, and (2) were there changes in rural hospital financial performance, staffing, or services after an M and A transaction? We used logistic regression to identify factors predictive of merger, and we used multiple regression to examine various hospital measures after an M or A. Study results showed that hospitals with weaker financial performance but lower staffing levels and staffing costs were more likely to merge or be acquired. Statistically weak evidence suggested that operating margins declined after the merger; stronger evidence suggested reductions in salary expense. There was no statistically significant evidence of changes to the number of full-time equivalent (FTE) employees, the service lines that were included in the study, capital expenditures, or the amount of debt financing among the hospitals that merged or were acquired. M and A may not result in a rapid influx of capital, a relief of debt burden, or an improvement in bottom-line profitability. However, M and A may be a viable option for maintaining the hospital and the access to care it provides.

PRACTITIONER APPLICATION: Rural Hospital Mergers and Acquisitions: Which Hospitals Are Being Acquired and How Are They Performing Afterward?

PRACTITIONER APPLICATION: Rural Hospital Mergers and Acquisitions: Which Hospitals Are Being Acquired and How Are They Performing Afterward?

PRACTITIONER APPLICATION: Hospital Acquisitions Before Healthcare Reform

PRACTITIONER APPLICATION: Hospital Acquisitions Before Healthcare Reform

Hospital Acquisitions Before Healthcare Reform

The hospital industry has experienced increased consolidation in the past 20 years. Since 2010, in particular, there has been a large rise in the number of hospital acquisitions, and observers have suggested this is due in part to the expected impact of federal healthcare reform legislation. This article reports on a study undertaken to identify the market, management, and financial factors affecting acute care, community hospitals acquired between 2010 and 2012. We identified 77 such hospitals and compared them to other acute care facilities. To assess how different factors were associated with acquisitions, the study used multiple logistic regressions whereby market factors were included first, followed by management and financial factors. Study findings show that acquired hospitals were located in markets with lower rates of preferred provider organization (PPO) penetration compared with nonacquired hospitals. Occupancy rate was found to be inversely related to acquisition rate; however, case-mix index was significantly and positively related to a hospital's being acquired. Financial factors negatively associated with a hospital's being acquired included age of plant and cash flow margin. In contrast to the findings from earlier studies of hospital acquisitions, our results showed that acquired hospitals possessed newer assets. However, similar to the findings of other studies, the cash flow margin of acquired hospitals was lower than that of nonacquired facilities.

The Impact of Hospital Acquisition of Physician Practices on Referral Patterns.

Multiple parties influence the choice of facility for hospital-based inpatient and outpatient services. The patient is the central figure, but their choice of facility is guided by their physician and influenced by hospital characteristics. This study estimated changes in referral patterns for inpatient admissions and outpatient diagnostic imaging associated with changes in ownership of three multispecialty clinic systems headquartered in Minneapolis-St. Paul, MN. These clinic systems were acquired by two hospital-owned integrated delivery systems (IDSs) in 2007, increasing the probability that hospital preferences influenced physician guidance on facility choice. We used a longitudinal dataset that allowed us to predict changes in referral patterns, controlling for health plan enrollee, coverage, and clinic system characteristics. The results are an important empirical contribution to the literature examining the impact of hospital ownership on location of service. When this change in ownership forged new relationships, there was a significant reduction in the use of facilities historically selected for inpatient admissions and outpatient imaging and an increase in the use of the acquiring IDS's facilities. These changes were weaker in the IDS acquiring two clinic systems, suggesting that management of multiple acquisitions simultaneously may impact the ability of the IDS to build strong referral relationships.

Effect of early clinical skills teaching on 3rd year medical students' learning: The student perspective

Abstract Objectives The main purpose of the early introduction of Clinical Skills Learning (CSL) to pre-clinical years is to allow medical students to gain experience in clinical examination skills, basic medical procedures, history-taking and clinical communication. The objective of this study was to determine the effectiveness of the early teaching of clinical skills in preparing medical students for their clinical years. Methods A validated questionnaire assessing the value of CSL on students in their first clinical year was distributed to 3rd year medical students. The questionnaire consisted of 8 items with a five-point Likert scale and one open-ended question. Results The response rate to the questionnaire was approximately 62%. Nearly 97 (70.8%) students suggested that CSL was a favourable teaching strategy. A high percentage of students (90.5%) agreed that CSL was a useful pre-clinical module to prepare them for their clinical years. The students gave positive feedback on the teaching of history-taking and physical examination, exposure to the hospital environment and acquisition of communication skills with supervisors and patients. No student perceived the CSL module as poor. Conclusions Early CSL was well-perceived by students in preparing them for their clinical years. CSL is a vital part of the pre-clinical curriculum and should be further enriched with frequent hospital visits to enhance students' confidence level and performance when interacting with patients during their clinical years.

Environmental transmission of Clostridium difficile: association between hospital room size and C. difficile Infection.

To evaluate the association between hospital room square footage and acquisition of nosocomial Clostridium difficile infection (CDI). A case-control study was conducted at a university hospital during the calendar year of 2011. Case patients were adult inpatients with nosocomial CDI. Control patients were hospitalized patients without CDI and were randomly selected and matched to cases in a 2:1 ratio on the basis of hospital length of stay in 3-day strata. A multivariate model was developed using conditional logistic regression to evaluate risk factors for nosocomial CDI. A total of 75 case patients and 150 control patients were included. On multivariate analyses, greater square footage of the hospital room was associated with a significantly increased risk of acquiring CDI (odds ratio for every 50 ft² increase, 3.00; 95% CI, 1.75-5.16; P<.001). Other factors associated with an increased risk of CDI were location in a single room (odds ratio, 3.43; 95% CI, 1.31-9.05; P=.01), malignant tumor (4.56; 1.82-11.4; P=.001), and receipt of cefepime (2.48; 1.06-5.82; P=.04) or immunosuppressants (6.90; 2.07-23.0; P=.002) within the previous 30 days. Greater room square footage increased the risk of acquisition of CDI in the hospital setting, likely owing to increased environmental contamination and/or difficulty in effective disinfection. Future studies are needed to determine feasible and effective cleaning protocols based on patient and room characteristics.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy.

The rapid diffusion of the surgical robot has been controversial because of the technology's high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy. We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors. In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy. Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Mergers When Prices Are Negotiated: Evidence from the Hospital Industry

We estimate a bargaining model of competition between hospitals and managed care organizations (MCOs) and use the estimates to evaluate the effects of hospital mergers. We find that MCO bargaining restrains hospital prices significantly. The model demonstrates the potential impact of coinsurance rates, which allow MCOs to partly steer patients toward cheaper hospitals. We show that increasing patient coinsurance tenfold would reduce prices by 16 percent. We find that a proposed hospital acquisition in Northern Virginia that was challenged by the Federal Trade Commission would have significantly raised hospital prices. Remedies based on separate bargaining do not alleviate the price increases. (JEL C78, G34, I11, I13, L13)

Clinical and molecular characterization of rhinoviruses A, B, and C in adult patients with pneumonia

BackgroundHuman rhinoviruses (HRVs) have increasingly been reported to be associated with lower respiratory tract infections. HRV-C has been associated with more severe respiratory illnesses in children. ObjectivesWe investigated the clinical and molecular characteristics of HRV-A, HRV-B, and HRV-C in adults with pneumonia. Study designHRV genotyping and quantitative real-time reverse-transcriptase polymerase chain reaction were performed on 392 adult respiratory specimens consecutively collected from June 2012 to May 2013. Pneumonia was identified by review of medical records and chest radiographs. ResultsAdult patients with pneumonia and identified HRV genotypes (n=165) were included. HRV-A, HRV-B, and HRV-C were identified in 97, 28, and 40 patients, respectively. No differences in underlying diseases, APACHE II score, or frequency of co-infection were observed between the HRV species. Compared with HRV-A, HRV-B was more often associated with neutropenia (21.4% vs. 7.2%, p=0.07), hospital acquisition (32.1% vs. 7.2%, p=0.048), and fever (78.6% vs. 49.3%, p=0.003). Mean viral load (copies/ml) was lower for HRV-B (102.6 vs. 104.1 in HRV-A and 104.3 in HRV-C), and high viral loads (≥104) occurred most frequently with HRV-C (70.0% vs. 57.7% for HRV-A and 21.4% for HRV-B). The incidence of severe pneumonia was similar for HRV-A (18.6%), HRV-B (21.4%), and HRV-C (20.0%), and in-hospital mortality rates did not differ significantly (15.5%, 10.7%, and 12.5%, respectively). ConclusionsIn contrast to previous pediatric studies, no differences were observed in clinical severity or outcomes between the different HRV species in adult patients with pneumonia.

No specific time window distinguishes between community-, healthcare-, and hospital-acquired bacteremia, but they are prognostically robust.

We examined whether specific time windows after hospital admission reflected a sharp transition between community and hospital acquisition of bacteremia. We further examined whether different time windows to distinguish between community acquisition, healthcare association (HCA), and hospital acquisition influenced the results of prognostic models. Population-based cohort study. Hospitals in 3 areas of Denmark (2.3 million inhabitants) during 2000-2011. We computed graphs depicting proportions of males, absence of comorbidity, microorganisms, and 30-day mortality pertaining to bacteremia 0, 1, 2, …, 30, and 31 days and later after admission. Next, we assessed whether different admission (0-1, 0-2, 0-3, 0-7 days) and HCA (30, 90 days) time windows were associated with changes in odds ratio (OR) and area under the receiver operating characteristic (ROC) curve for 30-day mortality, adjusting for sex, age, comorbidity, and microorganisms. For 56,606 bacteremic episodes, no sharp transitions were detected on a specific day after admission. Among the 8 combined time windows, ORs for 30-day mortality varied from 1.30 (95% confidence interval [CI], 1.23-1.37) to 1.99 (95% CI, 1.48-2.67) for HCA and from 1.36 (95% CI, 1.24-1.50) to 2.53 (95% CI, 2.01-3.20) for hospital acquisition compared with community acquisition. Area under the ROC curve changed marginally from 0.684 (95% CI, 0.679-0.689) to 0.700 (95% CI, 0.695-0.705). No time transitions unanimously distinguished between community and hospital acquisition with regard to sex, comorbidity, or microorganisms, and no difference in 30-day mortality was seen for HCA patients in relation to a 30- or 90-day time window. ORs decreased consistently in the order of hospital acquisition, HCA, and community acquisition, regardless of time window combination, and differences in area under the ROC curve were immaterial.

1649Acquisition of Clostridium difficile Associated with Potentially Contaminated Inpatient Rooms

1. Shaughnessy, Megan K., Renee L. Micielli, Daryl D. Depestel, Jennifer Arndt, Cathy L. Strachan, Kathy B. Welch, and Carol E. Chenoweth. Evaluation of Hospital Room Assignment and Acquisition of Clostridium Difficile Infection. Infection Control and Hospital Epidemiology 32.3 (2011): 201-206. Print. 2. Weber, David J., Deverick J. Anderson, Daniel J. Sexton, and Williams A. Rutala. Role of the environment in the transmission of Clostridium difficile in health. American Journal of Infection Control 41 (2013): S105-10. Print. References Geographically associated cases Room Dates same room was occupied Date 1st C. difficile positive

Epidemiology and Clinical Outcomes of Multidrug-resistant, Gram-negative Bloodstream Infections in a European Tertiary Pediatric Hospital During a 12-month Period

Bloodstream infections caused by multidrug-resistant, Gram-negative (MDRGN) bacteria represent a significant cause of morbidity and mortality. Prompt diagnosis and appropriate empiric treatment are the most important determinants of patient outcome. The objective of our study was to assess the epidemiology and clinical outcome of MDRGN sepsis in a tertiary-care pediatric hospital during a 12-month period. It was a retrospective, observational study of MDRGN bacteremia including all patients <18 years of age, hospitalized during 2011, with documented bacteremia caused by Enterobacteriaceae or non-fermentative bacteria. Overall, 136 blood cultures in 119 patients were included. The median age of patients was 1.1 years; 86.3% of patients had an underlying disease. The cumulative incidence of Gram-negative bloodstream infections was 5.4/1000 hospital admissions and the infection rate was 0.65/1000 hospital days. Most frequently isolated strains were Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa; 67.6% of infections were hospital acquired. The percentage of multidrug-resistant (MDR) organisms among isolated species was 39%. The crude rate of mortality was 16% and sepsis-related mortality was 9.2%. The mortality rate among patients with an antibiotic-resistant isolate was 22.6%. Factors significantly associated with sepsis-related mortality were antibiotic resistance (odds ratio: 4.26, 95% confidence interval: 1.07-16.9) and hospital acquisition of infection (odds ratio: 1.13, 95% confidence interval: 1.05-1.22). This study demonstrates the high mortality of hospital-acquired MDRGN bacteremia in children. International networks focusing on clinical management and outcomes of MDRGN in children are required. Study of novel antibiotics active against Gram-negative bacteria should include children early in the clinical trial development programs.

Hospital consolidation, competition, and quality: is bigger necessarily better?

A wave of hospital mergers during the last several years has raised concerns among US policy makers, regulators, and employers that increasing market consolidation may lead to higher health care spending as larger systems with greater market power extract higher prices from private payers. The number of hospital mergers or acquisitions has doubled since 2009, and many observers have pointed to the Affordable Care Act for transforming the economics of health care in ways that incentivize the creation of larger hospital systems.1 Although regulators are concerned about the effects of consolidation on health care prices, hospitals seeking to merge argue that larger, integrated systems will be able to provide substantially better care and achieve greater efficiencies.2 Whether these benefits result from consolidation is unclear. As federal regulators and policy makers weigh these issues, an assessment of the arguments that underlie the consolidation of the medical marketplace, and the potential influence of these arguments on clinical care

Impact of rapid molecular screening at hospital admission on nosocomial transmission of methicillin-resistant Staphylococcus aureus: cluster randomised trial.

DesignCluster randomised crossover trial with seven wards randomly allocated to intervention or control arm.SettingMedical and surgical wards of a university hospital with active MRSA control programme.ParticipantsAll patients hospitalized >48 h in study wards and screened for MRSA on admission and discharge Intervention: Rapid PCR-based screening test for MRSA compared with control screening test by enrichment culture using chromogenic agar.ObjectiveWe determined the benefit of PCR-detection versus culture-based detection of MRSA colonisation upon patient admission on early implementation of isolation precautions and reduction of hospital transmission of MRSA.Main outcomeCumulative rate of MRSA hospital acquisition of in patients screened negative on admission.RandomizationThe sequential order of inclusion of study wards in each arm was randomised by assigning a number to each ward and using a computer generated list of random numbers.FindingsOf 3704 eligible patients, 67.8% were evaluable for the study. Compared with culture, PCR-screening reduced the median test reporting time from admission from 88 to 11 hours (p<0.001) and the median time from admission to isolation from 96 to 25 hours (p<0.001). MRSA acquisition was detected in 36 patients (3.2%) in the control arm and 34 (3.2%) in the intervention arm. The incidence density rate of hospital acquired MRSA was 2.82 and 2.57/1,000 exposed patient-days in the control and intervention arm, respectively (risk ratio 0.91 (95% confidence interval, 0.60–1.39). Poisson regression model adjusted for colonisation pressure, compliance with hand hygiene and antibiotic use indicated a RR 0.99 (95% CI, 0.69 to 1.44).InterpretationUniversal PCR screening for MRSA on admission to medical and surgical wards in an endemic setting shortened the time to implement isolation precautions but did not reduce nosocomial acquisition of MRSA.Trial registrationclinicaltrials.gov NCT00846105

Where Does MRSA Live?

Source: Rodriguez M, Hogan GH, Burnham CA, et al. Molecular epidemiology of Staphylococcus aureus in households of children with community-associated S aureus skin and soft tissue infections. J Pediatrics. 2014; 164(1): 105– 111; doi: 10.1016/j.jpeds.2013.08.072Investigators from Washington University, St Louis, sought to determine if staphylococcal skin and soft tissue infections (SSTI) in children were acquired endogenously or from household members. Eligible patients (cases) were between 6 months and 20 years of age with a culture-confirmed methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-susceptible S aureus (MSSA) SSTI and were also colonized with S aureus in the anterior nares, axillae, or inguinal folds. Molecular typing was done to compare colonizing and infecting isolates in children with S aureus SSTI and their household contacts.Baseline colonization status was assessed for household contacts and index cases. Only the index cases were assessed for colonization status at 1-, 3-, 6-, and 12-month follow-up visits. PCR testing was performed on isolates from household contacts and on infecting and colonizing isolates of the index case at baseline and on any colonizing isolates at the 4 follow-up visits.In all, 163 cases and 562 household contacts were studied. At baseline, 64% of cases were colonized with MRSA, 28% with MSSA, and 9% with both; 68% were colonized at a body site proximal to the infection site. MRSA was cultured from the SSTI in 81% and MSSA in 19% of the index cases. Of the 562 household contacts, 55% were colonized with S aureus: MRSA in 20%, MSSA in 33%, both in 2%. Contacts colonized with MRSA were significantly more likely to have had a SSTI in the past year compared to those not colonized with MRSA (36% vs 17%).There were 27 distinct strains of S aureus identified from all of the 1,299 S aureus isolates. At baseline, 67% of the infected children had at least 1 colonizing strain that matched the strain cultured from their infected site and in 46% there was concordance with a household contact. Of those index cases whose infecting strain did not match the colonizing strain (32%), 28% had at least 1 household contact with a colonizing strain that matched the infecting strain. Over the 12 months of study, index cases carried up to 6 distinct strain types and during this time, 72% were colonized with at least 1 strain that matched the baseline infecting strains.The authors conclude that one third of the children with SSTI were not colonized with the infecting strain, and among these children only about one quarter had a concordant strain in a household contact. This suggests that S aureus infections are acquired from both within and outside the household.Dr Crandall has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.S aureus infections cause a broad range of clinical manifestations including SSTIs, bacteremia, and bone and joint infections. Historically MRSA was associated with hospital acquisition; however, community-associated MRSA (CA-MRSA) has emerged as a prevalent pathogen.1,2The epidemiology of SSTIs in the pediatric population is not completely understood but colonization with CA-MRSA is an established risk factor for acute infections.3 Strategies to prevent SSTI in children have focused on decolonizing the affected person and/or household with a regimen of intranasal antibiotic therapy in conjunction with antiseptic body washes. Although prophylactic decolonization is effective at decreasing S aureus carriage, it does not reduce the incidence of first-time SSTIs.4 Targeted decolonization of individuals with recurrent SSTIs and/or their household contacts, on the other hand, results in a modest reduction in recurrent SSTIs.5 However, it is unclear if removal of colonizing S aureus strains increases risk for acquisition of more virulent strains. Decolonization is currently only recommended in individuals and households with recurrent SSTI.6Overall, the results of this study indicate that a substantial number of SSTIs in children are caused by a strain of S aureus acquired outside the household. These results highlight the need for further investigation into the transmission of CA-MRSA in order to develop more effective strategies for disease prevention.While we await the unraveling of the mysteries of the ecology of MRSA, consider these measures which may decrease the household transmission: cessation of sharing personal items such as towels and washcloths, lotions, and bar soap, as well as the institution of dilute bleach baths (see AAP Grand Rounds, February 2012;27[2]:197).

MP59-16 RENAL ARTERY PSEUDOANEURYSMS AFTER NEPHRON SPARING SURGERY FOR RENAL CELL CARCINOMA: INCIDENCE, MANAGEMENT AND FUNCTIONAL OUTCOMES FROM CANADIAN KIDNEY CANCER INFORMATION SYSTEM DATABASE.

Procedures were categorized based on surgical technique and date of the relevant hospital’s acquisition of a surgical robot. Of the over cohort, surgical technique was: 38,904 (73%) open, 6875 (13%) laparoscopic, and 7627 (14%) robotic-assisted surgery. The change in percentage of surgical type (RN vs. PN) and procedure type (Open vs. Lap) was performed based on whether it occurred before or after the hospital acquired a surgical robot. RESULTS: Before a hospital acquired a surgical robot, on average 81.6% of all renal surgery performed were RN, and this decreased to 70.1% after robot purchase; PN utilization increased from 19.2% to 31.2% after introduction of the robotic system. Over the same time period, open renal surgery decreased from 85% to 58.9% and laparoscopic decreased from 15.0% to 13.5% (see table); with a subsequent increase in robotic surgery, all values significant p1⁄4<0.001. Additionally, we found that acquisition of a surgical robot increased the utilization of robotic prostatectomies and robotic gynecologic procedures. CONCLUSIONS: This is the first report suggesting an association between hospital acquisition of a surgical robot and increased utilization of PN over RN. This is encouraging as it suggests acquisition of a surgical robot is a significant factor in advancing the utilization of PN in the treatment of renal cell carcinoma.

PD17-08 THE EFFECT OF THE SURGICAL ROBOT ON THE HOSPITAL-LEVEL UTILIZATION OF PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The rapid diffusion of the surgical robot has been fraught with controversy because of the technology’s high costs and disputed marginal benefit. Some have suggested that adoption of the surgical robot has facilitated partial nephrectomy (PN), an underutilized procedure considered more challenging yet less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with a higher rate of PN. METHODS: We used the 2001, 2005 and 2008 Health-care Cost and Utilization Project State In-patient Databases from 7 states to identify 21,569 surgical procedures for renal tumors. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Survey and with publicly available data on timing of robot acquisition. We used a difference-in-difference model to assess whether robot acquisition was associated with an increase in the PN rate, adjusting for total nephrectomy rate, year of surgery, year of robot acquisition and several hospital-level factors. We performed two sensitivity analyses to determine whether there was a time lag between robot acquisition and changes in PN utilization (because of a presumed necessity to develop requisite surgical skill) and to ensure no association existed between robot acquisition and performance of an unrelated procedure (the presence of which might suggest an unmeasured confounding characteristic was the actual cause for increased surgical volume). RESULTS: In the multivariable adjusted differences-in-differences model (Figure 1), hospitals acquiring a robot between 2001-2005 performed more PN in both 2005 (30% increase) and 2008 (35% total increase) (p<0.01 for both). Hospitals acquiring a robot in the time period between 2005-2008 also demonstrated higher rates of PN in 2008 (16% increase) (p1⁄40.02). Results of the secondary lag time analysis were not substantially different. There was no association between robot acquisition and utilization of an unrelated surgical procedure. CONCLUSIONS: Hospital acquisition of the robot is associated with increased utilization of PN, a guideline-encouraged procedure. This is one of the few studies to suggest acquisition of the surgical robot was associated with a clear improvement in quality of care.