Minimum Volume Thresholds Research Articles

Hospital volume-outcome relationship in total knee arthroplasty: protocol for a systematic review and non-linear dose-response meta-analysis

BackgroundKnee osteoarthritis is a common, chronic condition and main contributor to global disability. Total knee arthroplasty (TKA) is the most successful treatment for end-stage knee osteoarthritis. It is assumed that in the field of surgery, there is a relationship between hospital volume and health outcomes and that higher hospital volume results in better health outcomes. As a consequence, minimum volume thresholds have been implemented in Germany for various procedures, including TKA (50 procedures per year). To date, it is unclear whether minimum volume thresholds truly result in better outcomes.The objective of this study will be to quantify the relationship between hospital volume and patient-relevant outcomes in patients undergoing TKA.MethodsWe will include published or unpublished (cluster-) randomized controlled trials and prospective or retrospective cohort studies that involve patients with primary and/or revision TKA, report at least two different hospital volumes and report at least one patient-relevant outcome. To identify studies, we will systematically search (from inception onwards) PubMed/MEDLINE, Embase, CENTRAL, and CINAHL, as well as trial registers, conference proceedings, and reference lists. We will also contact experts in the field. Study selection and data extraction will be performed by two reviewers independently. The primary outcome will be rate of early revision. Secondary outcomes will include rate of revision > 1 year, mortality, length of stay, readmission rate, surgical complications, adverse events and health-related quality of life. We will assess the risk of bias of the included studies using ROBINS-I or the Cochrane risk of bias tool. Both a linear and a non-linear dose-response meta-analyses will be performed. We will use the GRADE approach to evaluate our confidence in the cumulative evidence. We will incorporate patients’ needs, goals and preferences into our recommendations by consulting three focus groups, each consisting of eight participants.DiscussionThe findings of our systematic review will probably be limited by the design of the included studies. We do not expect to identify any (cluster-) randomized controlled trials that meet our inclusion criteria. Therefore, the best available evidence included in our systematic review will most likely consist of cohort studies only. We anticipate that the results of this study will inform future health policy decisions in Germany regarding the minimum volume threshold for TKA.Systematic review registration: PROSPERO CRD42019131209

Correction: Patient Preferences between Minimum Volume Thresholds and Nationwide Healthcare Provision: the Example of Total Knee Arthroplasty.

Correction: Patient Preferences between Minimum Volume Thresholds and Nationwide Healthcare Provision: the Example of Total Knee Arthroplasty.

Impact of resistance training program configuration on the circulating brain-derived neurotrophic factor response.

This study examined the acute and resting changes of brain-derived neurotrophic factor (BDNF) and inteleukin-6 (IL-6) and if changes in these biomarkers were correlated during resistance training (RT). Fifteen men with ≥2 years of RT experience (age: 23 ± 3 years, body mass: 84.4 ± 12.3 kg) participated. Subjects performed RT 3×/week for 6 weeks in either a high-repetition (HR; n = 8) or low-repetition (LR; n = 7) group. Protocols during week 1 were HR - Monday: 4 (sets) × 12 (repetitions) at 60% of 1-repetition maximum, Wednesday: 4 × 10 at 65%, Friday: 5 × 8 at 70%; LR - Monday: 8 × 6 at 75%, Wednesday 9 × 4 at 80%, Friday: 10 × 2 at 85%. Total volume was equated for the 6 weeks but not for individual sessions. Greater volume and intensity were performed in LR versus HR (p < 0.01) on Mondays. Plasma was collected immediately before and after exercise of the Monday session. There were no significant interactions or main effects for BDNF (p > 0.05). There was a moderate between-group effect size (0.57) in favor of LR in week 6, suggesting a potentially greater acute increase in BDNF in LR versus HR. For IL-6, a statistically significant main effect was observed for training (p < 0.0001), showing an acute increase in IL-6 in both weeks (p < 0.01); however, no other 3-way or 2-way interactions existed (p > 0.05). A minimum volume threshold of RT may be needed to induce acute elevations in BDNF. Novelty A minimum RT volume threshold may be needed to elicit BDNF. A close proximity to failure may be needed to elicit BDNF. BDNF and IL-6 did not correlate.

PCN299 MINIMUM VOLUME STANDARDS IN FRENCH HOSPITALS FOR BREAST CANCER AND OVARIAN CANCER - INEQUALITIES IN ACCESS TO HOSPITAL CARE

The Volume-Outcome Relationship in health economics has been the subject of extensive investigation. To date, most of the studies have found that higher-volume hospitals have better outcomes (e.g., lower mortality rates). These results have shed light on the need to set minimum-volume regulations in order to increase the overall quality of care. In 2018, the French National Health Insurance proposed to increase the minimum-volume threshold for breast cancer from 30 to 150 surgeries per year, and to set a specific threshold for ovarian cancer at 10 cases per year in order to get an authorization to treat these patients. Although increasing minimum-volume thresholds has been shown to improve quality of care, it may also have adverse consequences on patients’ inequalities in access. The aim of this study is to simulate the application of minimum volume threshold for breast cancer and ovarian cancer in France, and explore their impact on socio-economics inequalities. We modelled patients flows from low to high volume hospitals in terms of probabilities of patients choice of provider based on a revealed preferences framework. We used an exhaustive nationwide administrative dataset (Medical Information Systems Program) of 57726 (4034) patients surgically treated for breast cancer (ovarian cancer) in mainland France in 2018. Our results indicate that the application of minimum volume-threshold in France will be very effective to centralize care for breast cancer and ovarian cancer treatment. However, our findings indicate that it will introduce strong inequalities in access to specialized care in terms of travel distance, and will contribute to the medical desertification in rural areas that have already less access to non-specialized care. To devise volume-based policies, policy makers will have to considered its impact on inequalities in access to hospital care in order not to penalize rural areas already suffering from medical desertification.

Identifying the Minimum Volume Threshold for Retroperitoneal Soft Tissue Sarcoma Resection: Merging National Data with Consensus Expert Opinion

The complexity of retroperitoneal soft tissue sarcoma (RPS) surgery has prompted international recommendations to regionalize it to high-volume hospitals (HVHs). A minimum procedural volume threshold for RPS is not yet defined, hampering effective referral and regionalization in the US. This multihospital study sought to establish an HVH threshold informed by national data and international expert opinion. The 2004-2015 National Cancer Database identified 8,721 surgically treated RPS patients. Multivariable models, using linear splines, identified annual volume thresholds predictive of overall and 90-day mortality. Transatlantic Australasian Retroperitoneal Soft Tissue Sarcoma Working Group members (n= 48) completed a 15-item survey regarding these data. Overall mortality risk was reduced by 4% per additional case (hazard ratio [HR] 0.96, 95% CI 0.95 to 0.98) up to a threshold of 13 cases/year; no further reduction was observed over 13 (HR 0.99, 95% CI 0.97 to 1.01). After revealing the results from our statistical analysis, 71.4% of respondents who initially chose >30 cases/year as a cutoff shifted their response to a lower value. More than 56% cited 11 to 20 procedures/year as the cutoff for an HVH. Median survival in hospitals with <13 vs >13 cases/year was 94 vs 139 months, respectively (p < 0.001). Forty percent of respondents cited 1% to 2% as an acceptable90-day mortality. This was achieved with a minimum of 13 cases/year based on risk-adjusted survival analysis. This is the first multicenter analysis to merge data-driven RPS surgery volume thresholds to clinically meaningful sarcoma expert opinions. These findings will help inform national/international consensus recommendations, a practical volume threshold, trial design, and motivate evidence-based hospital referral.

Identifying the Minimum Volume Threshold for Retroperitoneal Soft Tissue Sarcoma Resection: Merging National Data with Consensus Expert Opinion

Identifying the Minimum Volume Threshold for Retroperitoneal Soft Tissue Sarcoma Resection: Merging National Data with Consensus Expert Opinion

Patient Preferences between Minimum Volume Thresholds and Nationwide Healthcare Provision: the Example of Total Knee Arthroplasty.

The aim of this study is to investigate, whether patients in Germany are willing to travel a longer time to a certain hospital in order to receive a better treatment (lower 90-days mortality, lower risk of revision) in elective total knee arthroplasty. In addition, we analyzed which characteristics determined patient preference. The participants were recruited via random samples of registration offices and hospitals. All have undergone discrete choice experiments for the outcomes mortality and revision. Descriptive statistics were used to analyze the patient's preference. Logistic regression models were applied to identify characteristics that influence decision making. 71.7% (mortality) and 86.11% (revision) of the respondents are willing to travel a longer time in order to lower their surgical risk. The amount of people that are willing to do so is even larger in the subgroup recruited in the hospital (78.5% respectively 90.7%). The majority of the participants are willing to travel longer to lower their surgical risk for elective knee arthroplasty. It has to be considered, that the population under study might not be representative. Patient's preferences corresponds with the aim of introducing minimum volume thresholds. Future studies should focus on other indications and outcomes.

Association Between Hospital Market Concentration and Costs of Laryngectomy

High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined. To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy. The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018. Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy. Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%). Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.

Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?

We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4). Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

Increasing surgeon volume correlates with patient survival following open abdominal aortic aneurysm repair

ObjectiveThe annual number of open abdominal aortic aneurysm (AAA) repairs has decreased dramatically over the last decade, making the search for physician case volume thresholds more important. The purpose of this study was to identify a minimum threshold for annual surgeon case volume in open AAA repair. MethodsThe New York Statewide Planning and Research Cooperative System inpatient database was used to identify all patients undergoing open repair of an intact AAA between 2000 and 2008. Thirty-day survival was calculated using New York State vital records, which contain all New York State death certificates. The annual case volume for each surgeon was defined as the number of open AAA repairs performed in the year of the index procedure. The Contal and O'Quigley method was used to identify a minimum volume threshold. ResultsA total of 11,086 patients were included in the analysis. The selected cutpoint was six or more cases per year based on maximization of the Contal and O'Quigley test statistic. The high-volume group had comparable rates of cardiovascular comorbidities, but significantly improved 30-day and 5-year survival rates as well as shorter lengths of stay in the hospital. ConclusionsThis study identifies an ideal threshold for minimum annual surgeon case volume for open AAA repair. Over the study period, perioperative mortality would not have occurred in up to 150 patients if all procedures had been done by high-volume surgeons performing at least six repairs per year. However, even a minimum annual threshold of at least two repairs per year provided a mortality benefit. Ideal minimum volume thresholds should be developed using rigorous statistical analysis as well as local information about practice patterns.

Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer

A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures. To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes. In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable. Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis. Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900). Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.

Is an activity volume threshold really realistic for lung cancer resection?

We analyzed volume as a continuous variable to estimate threshold, which is a methodology rarely seen in the literature. The objective of this work was to assess hospital volume for lung cancer (LC) surgery and to establish the associated threshold for acceptable in-hospital mortality (IHM). Data was obtained from the French national medico-administrative database. From January 2005 to December 2016, data from 108,571 patients operated for LC in France were collected from the national administrative database. To estimate the volume threshold, hierarchical logistic regression models were developed. The crude IHM rate was 5.2% in low volume centers and 3.5% in high volume centers (P<0.0001). Centers performing more than 70 LC surgeries per year reduced the risk of postoperative death by 35% [adjusted odds ratio (OR): 0.65; 95% confidence interval (CI): 0.5-0.84]. Among the 4 models, the use of fractional polynomial of the volume had the lowest Akaike's information criterion (AIC) index. The threshold volume was reached once a hospital's annual volume reached 70 patients (95% CI, 40-85). In our analyses, the proportion of patients who were admitted in hospitals with an annual volume that was less than identified threshold were 34% of patients operated for LC. A hospital with an annual volume of 10 patients for lung resection, increasing the annual volume by 60 procedures would be associated with a 31% reduction in the odds of death within 30 days. From the medico-administrative database, we have been able to estimate a minimum volume threshold that may be useful to help regionalize thoracic surgery centers.

Impact of institutional procedural volume on inhospital outcomes after cardiac resynchronization therapy device implantation: US national database 2003–2011

The relationship between hospital volume and outcomes for cardiac resynchronization therapy (CRT) implantations has not been well established. The purpose of this study was to examine outcomes after CRT device implantation stratified by hospital volume using a large national inpatient database. Using the National Inpatient Sample database, we identified all patients undergoing de novo CRT implants between 2003 and 2011. Hospitals were categorized according to tertiles of annual CRT procedural volume. Rates of inhospital adverse events including death, cardiac perforation, pneumothorax, and lead revision were examined. A multivariate logistic regression analysis was performed to compare outcomes across hospital volume categories. Between 2003 and 2011, 410,104 de novo CRT implantations were performed. More than half (50.9%) of hospitals performed ≤16 CRT implants/y. Overall complication rates were higher in the lower-volume centers (3.9%, 3.5%, and 3.2%; P=.001) when stratified by first, second, and third tertiles of CRT volume, respectively. The lowest tertile of CRT volume was independently associated with increased inhospital all-cause mortality (adjusted odds ratio [OR] 1.37; 95% confidence interval [CI] 1.10-1.70; P = .005), any complication (adjusted OR 1.21, 95% CI 1.07-1.37; P = .003), and lead revision (adjusted OR 1.27; 95% CI 1.03-1.58; P = .03). Lower CRT hospital volume was associated with worse outcomes, including inhospital death, overall complications, and lead revision. Establishment of standards defining minimum CRT volume thresholds to identify centers of excellence may result in improved outcomes.

Hospital volume and mortality for 25 types of inpatient treatment in German hospitals: observational study using complete national data from 2009 to 2014

ObjectivesTo explore the existence and strength of a relationship between hospital volume and mortality, to estimate minimum volume thresholds and to assess the potential benefit of centralisation of services.DesignObservational population-based...

Implications of the getting it right first time initiative for regional knee arthroplasty services

Study aimThe aim of this case study of regional orthopaedic practice was to estimate the potential impact of the GIRFT recommendations (iGIRFT) of minimum unit and surgeon specific volumes to orthopaedic units within the Severn Region, UK. MethodPractice profiles for surgeons and units were generated using the UK National Joint Registry Surgeon and Hospital Profile Database. Minimum volume thresholds were set at 13 procedures/year for surgeons and 30 procedures/year for units. ResultsFive thousand five hundred seventeen knee arthroplasty procedures were recorded within the Severn Region between 1st of January and 31st December 2012 and these were performed by 94 surgeons in 18units. During this time, 4232 (76.7%) primary TKR, 751 (13.6%) primary UKR, 97 (1.7%) primary PFJR and 437 (7.9%) revision TKR were performed. Median surgeon volumes were 33 (range two to 180) for primary TKR, ten (range 2 to 64) for UKR, two (range two to 41) for PFJR and five (range two to 57) for Revision TKR. Amongst 48 surgeons performing UKR, 26 (54%) performed less than 13 procedures per year accounting for 108 (14%) procedures. Amongst 20 surgeons performing PFJR, 19 (95%) performed <13/year, accounting for 56 (58%) of cases. Fifty surgeons performed revision TKR with 37 (74%) performing <13 revisions per annum, accounting for 151 (35%) procedures. Amongst 16units performing UKR, eight (50%) performed <30/year, accounting for 16% overall. Revision TKR was performed in 15units whilst eight (53%) performed <30/year, accounting for 62 (15%) cases. ConclusionWe have hypothesised the impact of implementing minimum unit and surgeon volume thresholds for the organisation of regional arthroplasty services. Our analysis suggests that whilst these effects may be considerable, they may be mitigated by local rationalisation to achieve an appropriate caseload mix.

Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States

There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes. To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized. Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016. Incidence of any complication. Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04). Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.

Relationship between surgeon volume and outcomes: a systematic review of systematic reviews.

BackgroundThe surgeon volume-outcome relationship has been discussed for many years and its existence or nonexistence is of importance for various reasons. A lot of empirical work has been published on it. We aimed to summarize systematic reviews in order to present current evidence.MethodsMedline, Embase, Cochrane database of systematic reviews (CDSR), and health technology assessment websites were searched up to October 2015 for systematic reviews on the surgeon volume-outcome relationship. Reviews were critically appraised, and results were extracted and synthesized by type of surgical procedure/condition.ResultsThirty-two reviews reporting on 15 surgical procedures/conditions were included. Methodological quality of included systematic reviews assessed with the assessment of multiple systematic reviews (AMSTAR) was generally moderate to high albeit included literature partly neglected considering methodological issues specific to volume-outcome relationship. Most reviews tend to support the presence of a surgeon volume-outcome relationship. This is most clear-cut in colorectal cancer, bariatric surgery, and breast cancer where reviews of high quality show large effects.ConclusionsWhen taking into account its limitations, this overview can serve as an informational basis for decision makers. Our results seem to support a positive volume-outcome relationship for most procedures/conditions. However, forthcoming reviews should pay more attention to methodology specific to volume-outcome relationship. Due to the lack of information, any numerical recommendations for minimum volume thresholds are not possible. Further research is needed for this issue.Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0376-4) contains supplementary material, which is available to authorized users.

Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures

In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births. Publicly available Joint Commission Quality Check data from April 2014 to March 2015 for three Perinatal Care measures were linked to Medicare Provider of Services and American Hospital Association Annual Survey data. For each measure, hospital-level reporting and performance among accredited hospitals providing obstetric care were compared using Fisher's exact tests. Sixty-seven percent of the 2,396 accredited hospitals with obstetric services reported at least one eligible patient for two of the four reported Perinatal Care measures: Elective delivery and exclusive breast milk feeding. Fewer hospitals (35.0%) had data on the antenatal steroids measure; many hospitals may not have any eligible patients for this measure. Hospitals with higher birth volume, those in urban counties, and those with private, nonprofit ownership or system affiliation were more likely to report the perinatal measures (p < 0.001). Across states, reporting rates varied considerably. By hospital volume, performance varied more on the antenatal steroids measure (78.0% to 91.5%) than on the breast milk feeding measure (48.4% to 49.5%) and the elective delivery measure (2.5% to 3.0%). Expansion of the minimum birth volume threshold nearly doubles the number of accredited hospitals required to report the Perinatal Care measures to The Joint Commission. However, 485 accredited hospitals with obstetric services that are either critical access hospitals or have fewer than 300 births annually are still exempt from reporting. Although many rural hospitals remain exempt from reporting requirements, the measures offer an opportunity for both rural and urban hospitals to assess and improve care.

Construction QA/QC Methods for Postgrouting Drilled Shafts

AbstractThe design and anticipated end-bearing capacity of postgrouted drilled shafts hinge on achieving sufficient grout pressure applied to the soils beneath the shaft tip. Implied, however, is that the grout is distributed reasonably well across the entire tip area. To this end, minimum grout pressure and volume thresholds are usually prescribed in an effort to address both concerns. Unfortunately, it is difficult to practically ascertain the actual area of the grout bulb during production grouting when manually-recorded values of pressure, volume, and uplift are the only available information. Therein, artificially-high grout pressure can be recorded, resulting from a blocked grout-distribution system that goes undetected and the shaft is accepted as both the minimum pressure and volume criteria were satisfied. This article outlines minimum monitoring practices and field quality-assurance/quality-control (QA/QC) measures that can and should be used to better ensure tip grouting is performed in conform...

SU‐E‐J‐242: Volume‐Dependence of Quantitative Imaging Features From CT and CE‐CT Images of NSCLC

Purpose:To determine whether tumor volume plays a significant role in the values obtained for texture features when they are extracted from computed tomography (CT) images of non‐small cell lung cancer (NSCLC). We also sought to identify whether features can be reliably measured at all volumes or if a minimum volume threshold should be recommended.Methods:Eleven features were measured on 40 CT and 32 contrast‐enhanced CT (CECT) patient images for this study. Features were selected for their prognostic/diagnostic value in previous publications. Direct correlations between these textures and volume were evaluated using the Spearman correlation coefficient. Any texture that the Wilcoxon rank‐sum test was used to compare the variation above and below a volume cutoff. Four different volume thresholds (5, 10, 15, and 20 cm3) were tested.Results:Four textures were found to be significantly correlated with volume in both the CT and CE‐CT images. These were busyness, coarseness, gray‐level nonuniformity, and run‐length nonuniformity with correlation coefficients of 0.92, −0.96, 0.94, and 0.98 for the CT images and 0.95, −0.97, 0.98, and 0.98 for the CE‐CT images. After volume normalization, the correlation coefficients decreased substantially. For the data obtained from the CT images, the results of the Wilcoxon rank‐sum test were significant when volume thresholds of 5–15 cm3 were used. No volume threshold was shown to be significant for the CE‐CT data.Conclusion:Equations for four features that have been used in several published studies were found to be volume‐dependent. Future studies should consider implementing normalization factors or removing these features entirely to prevent this potential source of redundancy or bias.This work was supported in part by National Cancer Institute grant R03CA178495‐01. Xenia Fave is a recipient of the American Association of Physicists in Medicine Graduate Fellowship.