Risk-adjusted Benchmarking Research Articles

Abstract 16273: Contemporary Risk Prediction Model for In-Hospital or 30-day Mortality After Percutaneous Coronary Interventions: An NCDR CathPCI Registry Model

Introduction: While the ACC NCDR CathPCI registry has long provided risk-adjusted benchmarking of in-hospital mortality after percutaneous coronary intervention (PCI), extending follow-up to 30 days in those who are discharged can provide a more comprehensive assessment of post-PCI outcomes. Aims: We sought to develop a new model for predicting in-hospital or 30-day mortality after PCI with excellent discrimination to be used for quality improvement efforts. Methods: Data from 472,594 PCIs performed in 2019 at 1,369 sites from the CathPCI registry linked to National Death Index data were used to identify pre-procedural and angiographic predictors of mortality and develop a predictive model of in-hospital or 30-day mortality. A thousand bootstrapped samples of the development cohort were created, and stepwise logistic regression was performed on each sample. The final model included variables that were selected in at least 70% of the bootstrapped samples. Results: The overall in-hospital or 30-day mortality rate after PCI in the entire cohort was 2.8%. In those undergoing elective PCI without shock or clinical instability, mortality was 0.5%, while in those undergoing salvage PCI or for refractory shock it was 60.3% . Cardiovascular instability, level of consciousness after cardiac arrest, frailty, and chronic kidney disease stage were the factors most predictive of mortality (Table 1). The full model performed well with good discrimination in the overall population (C-index= 0.907), and in the cohorts of patients with STEMI (c-index=0.899), and cardiac arrest or shock (c-index=0.828), as well as across the spectrum of procedural risk. Conclusions: This risk model can accurately predict in-hospital or 30-day mortality in those undergoing PCI by incorporating variables that capture cardiovascular instability and clinical status. Extending the mortality follow-up period should enable for a more standardized evaluation of outcomes across hospitals.

Abstract 16570: Benchmarking Risk-Adjusted Outcomes in Congenital Heart Surgery

Background: Robust models exist to predict risk-adjusted mortality following congenital heart surgery. It is known that underlying diagnosis modifies predicted risk of operations, and institution-level outcomes vary based on their unique case mix. We therefore evaluated risk-adjusted outcomes for a subset of diagnosis-procedure (D-P) combinations within the Society of Thoracic Surgeons' (STS) congenital heart surgery database (CHSD). Methods: A clinician panel identified the most frequently encountered D-P combinations in CHSD between 07/2017 and 06/2021. Candidate modeling techniques were compared in a random 80% development cohort. Model performance was assessed using internal and cross-validation calibration, discrimination plots and optimism adjusted C-statistics. The final selected model was evaluated in the 20% validation sample. Results: The chosen subset of D-P combinations represented 45,384 of 87,589 (52%) unique episodes of surgical care in CHSD during this time-period. The development cohort (36,350 episodes) had 1.8% mortality (667 deaths). All candidate models had excellent discrimination with C-statistics ranging from 0.862 to 0.876. The model with the best combination of discrimination, calibration, and clinical face validity was a modified version of the current STS mortality risk model. This version included all current risk model variables with the addition of indicator variables for D-P combinations. In the 20% validation sample (9,034 episodes), this model was well calibrated (Figure) and had excellent discrimination (C = 0.879). Conclusion: We describe a cohort of D-P combinations widely encountered in the STS CHSD. Further, we refined the existing STS CHSD risk model for application to these D-P dyads to derive empirical risk-adjusted benchmark outcomes. This approach will benefit quality improvement efforts at an institutional level and may have implications for publicly reporting congenital heart surgery outcomes.

Risk-adjusted benchmarking of long-term overall survival in patients with HER2-positive early-stage Breast cancer: A Swedish retrospective cohort study.

The main objective of the current study was to explore the value of risk-adjustment when comparing (i.e. benchmarking) long-term overall survival (OS) in breast cancer (BC) between Swedish regions. We performed risk-adjusted benchmarking of 5- and 10-year OS after HER2-positive early BC diagnosis between Sweden's two largest healthcare regions, constituting approximately a third of the total population in Sweden. All patients diagnosed with HER2-positive early-stage BC between 01-01-2009 and 31-12-2016 in healthcare regions Stockholm-Gotland and Skane were included in the study. Cox proportional hazards model was used for risk-adjustment. Unadjusted (i.e. crude) and adjusted 5- and 10-year OS was benchmarked between the two regions. The crude 5-year OS was 90.3% in the Stockholm-Gotland region and 87.8% in the Skane region. The crude 10-year OS was 81.7% in the Stockholm-Gotland region and 77.3% in the Skane region. However, when adjusted for age, menopausal status and tumour biology, there was no significant OS disparity between the regions, neither at the 5-year nor 10-year follow-up. This study showed that risk-adjustment is relevant when benchmarking OS in BC, even when comparing regions from the same country that share the same national treatment guidelines. This is, to our knowledge, the first published risk-adjusted benchmarking of OS in HER2-positive BC.

An assessment of the provider financial risk impacts of adoption of biosimilars in the Medicare Oncology Care Model.

6613 Background: In 2016, Medicare launched the Oncology Care Model (OCM)—a Value-Based Payment (VBP) initiative providing per-beneficiary prospective payment to providers, and performance-based financial incentives/risks based on cost of care in 6-month ‘episodes’ vs. risk-adjusted benchmarks for cancer patients receiving chemotherapy. Oncology biosimilars may play an important role in managing financial risk in the OCM and other VBP models, but the real-world impact remains uncertain. The objective of this study was to quantify the impact of biosimilar adoption on oncology provider financial risk under the OCM using real-world data. Methods: We estimated the impact of biosimilar adoption on provider financial risk from 2019 to 2021 by modeling the methods (episode framing, pricing, & risk adjustment) of the OCM. Cancer episodes were identified from the 5% Medicare Limited Data Set (LDS). The study sample consisted of cancer treatment episodes with use of any of the following agents or their biosimilars: bevacizumab, rituximab, trastuzumab, epoetin alfa, filgrastim, and pegfilgrastim. Financial risk was defined as the difference in observed total cost of care vs. OCM target episode cost. The primary outcome was the difference in financial risk (expressed in nominal $USD) under observed use of reference and/or biosimilars vs. hypothetical use of 100% reference agent. Results: The study sample included 8851 6-month episodes initiating between 1/2019 and 6/2021. Biosimilar adoption resulted in a mean cost reduction of $1,020 per episode vs. hypothetical 100% use of reference agents. Biosimilar use increased markedly over the study horizon--with 24% of episodes with a biosimilar in Half (H)1 2019, increasing to 65% by H1 2021, and driven by increased use of antineoplastic (1% to 36%) vs. supportive care biosimilar agents (23% to 34%). Mean financial risk reduction grew with the rapid adoption of biosimilars over this period. The average risk reduction in episodes initiating in H1 2021 was about 10 times larger than that seen in episodes initiating in the H1 2019 ($2060 vs $201, See Table). Observed mean cost was below the OCM target cost ($48808) in H1 2021 but exceeded the target cost in all other periods (range: +$1451 to +$4966). Conclusions: From 2019 to 2021, rapid adoption of biosimilars in Medicare fee-for-service beneficiaries included in the LDS led to substantial cost savings and reduction in risk for cancer episodes evaluated under the OCM methods. Broad adoption of biosimilars is a key strategy that providers in oncology VBP models will need to consider to manage financial risk. [Table: see text]

Democratizing Wealth Management

Over the past 25 years, as access to pensions has declined and longevity has increased, people have needed to bear increasing responsibility for their financial well-being. Fortunately, wealth management has become democratized in that time, bringing to a greater number of people the techniques that once were available only to institutions and the very wealthy. Alpha, the value added relative to an appropriate risk-adjusted benchmark, has been shrinking for a variety of reasons. However, factor-based investing has grown, offering a convenient way to access the premiums once assigned to alpha. Tax-aware mutual funds have become more common, while the rise of exchange-traded funds allows investors to defer capital gains. Continuing advances in efficiency have enabled separately managed accounts to be offered for lower assets and at lower costs. The appropriate vehicle depends on the specifics of the investor, the characteristics of the strategy, and the type of account where it is held. Wealth management should continue to evolve to meet the needs of investment professionals and those they serve.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.

Perceptions of an automated benchmarking dashboard for antimicrobial stewardship programs among antimicrobial stewards within the veterans' health administration: a multicenter qualitative study.

To evaluate the impact of a multicenter, try automated dashboard on ASP activities and its acceptance among ASP leaders. Frontline stewards were asked to participate in semi-structured interviews before and after implementation of a web-based ASP information dashboard providing risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility. The study was performed at Iowa City VA Health Care System. ASP team members from nine medical centers in the VA Midwest Health Care Network (VISN 23). Semi-structured interviews were conducted pre- and post-implementation, with interview guides informed by clinical experiences and the Consolidated Framework for Implementation Research (CFIR). Participants evaluated the dashboard's ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and relative advantage over other ASP monitoring systems. Compared to established stewardship data collection and reporting methods, participants found the dashboard more intuitive and accessible, allowing them to reduce dependence on other systems and staff to obtain and share data. Standardized and risk-adjusted rankings were largely accepted as a valuable benchmarking method; however, participants felt their facility's characteristics significantly influenced the rankings' validity. Participants recognized staffing, training, and uncertainty with using the dashboard as an intervention tool as barriers to consistent and comprehensive dashboard implementation. Participants generally accepted the dashboard's risk-adjusted metrics and appreciated its usability. While creating automated tools to rigorously benchmark antimicrobial use across hospitals can be helpful, the displayed metrics require further validation, and the longitudinal utility of the dashboard warrants additional study.

NSQIP Quality Benchmarking and Evaluation of Potential Bias Associated with Higher- or Lower-Risk Operation Case Mix.

To ensure validity and acceptance of NSQIP risk-adjusted benchmarking, it is important that adjustments adequately control for hospitals that vary in their proportions of lower- or higher-risk operations (combined risk for procedure and patient). This issue was addressed in separate empirical and simulation studies. For the empirical study, potential miscalibration bias favoring hospitals that do lower-risk operations or disfavoring hospitals that do higher-risk operations was evaluated for 14 modeled outcomes using NSQIP data. A determination was also made as to whether there was a relationship between mean hospital operation risk and benchmarking results (log odds ratio). In the simulation study of the same 14 outcomes, hospital benchmarked performance was evaluated when sampled cases were reconstituted to include either a larger proportion of lower-risk operations or a larger proportion of higher-risk operations. Miscalibration favoring either lower- or higher-risk operations was absent, as were important associations between operative risk and hospital log odds ratios (most model R 2 less than 0.01). In the simulation, there were no substantial changes in log odds ratios when greater percentages of either lower- or higher-risk operations were included in a hospital's sample (nonsignificant p values and effect sizes less than 0.1). These results should enhance NSQIP participants' confidence in the adequacy of NSQIP patient and procedure risk-adjustment methods. NSQIP participants may rely on benchmarking findings, and implement quality improvement efforts based on them, without concern that they are biased by a preponderance of lower or higher risk operations.

Medicare Advantage Financing and Quality in Puerto Rico vs the 50 US States and Washington, DC

More than 70% of Medicare beneficiaries in Puerto Rico are enrolled in a Medicare Advantage (MA) plan. Evidence of MA plan payments and quality in Puerto Rico compared with the 50 US states and Washington, DC (hereafter referred to as US mainland), is lacking, notably after implementation of the Patient Protection and Affordable Care Act (ACA). To compare MA plan payments and quality in Puerto Rico with those in the US mainland and to evaluate how differences between MA plans in Puerto Rico and the US mainland changed after ACA implementation. This cohort study used publicly available data on MA plans from January 1, 2006, to December 31, 2019, from the Centers for Medicare & Medicaid Services. Data analysis was performed from October 2019 to February 2022. Medicare Advantage plans in Puerto Rico and implementation of the ACA. Primary outcomes were risk-standardized federal benchmark payments (the amount offered by the federal government for insuring a beneficiary of average risk), risk-standardized plan bids (a plan's asking price for a beneficiary of average risk), and rebates received by plans. Additional outcomes included risk-adjusted benchmarks, risk-adjusted bids, actual plan payment, and aggregate plan quality ratings (star ratings). A difference-in-differences analysis examined differential changes in plan payments in Puerto Rico vs the US mainland after ACA implementation. Before ACA implementation, 211 MA plans in Puerto Rico and 13 899 plans in the US mainland were included. After ACA implementation, 433 MA plans in Puerto Rico and 29 515 plans in the US mainland were included. Before ACA implementation, risk-standardized benchmarks were 33% lower for MA plans in Puerto Rico than plans in the US mainland ($556.73 [95% CI, $551.82-$561.64] vs $831.15 [95% CI, $828.55-$833.75] per beneficiary per month [PBPM]). This gap increased to 38% after ACA implementation ($540.58 [95% CI, $536.86-$544.32] vs $869.31 [95% CI, $868.21-$870.42] PBPM). Risk-standardized plan bids in Puerto Rico were 46% lower before ACA implementation and 43% lower after ACA implementation compared with those in the US mainland. Rebates in Puerto Rico decreased from $168.50 (95% CI, $163.57-$173.42) PBPM before ACA implementation to $93.39 (95% CI, $89.51-$97.27) PBPM after ACA implementation, a decrease of $75.11 PMPM compared with a decrease of $2.05 PMPM in the US mainland. Plans in Puerto Rico received increased quality bonus payments, and the mean (SD) risk score for plans in Puerto Rico increased to 1.55 (0.31) after ACA implementation, which increased risk-adjusted benchmarks and actual plan payments, offsetting the widening payment disparity. This cohort study found that after implementation of the ACA, federal benchmark payment amounts decreased in Puerto Rico compared with the US mainland. Responses by MA plans in Puerto Rico, including increased quality bonus payments and risk scores, offset this payment reduction, although actual plan payments in Puerto Rico were lower than those in the US mainland.

Qualitative Evaluation of an automated nationwide benchmarking antimicrobial utilization dashboard for the VHA

Background: Antimicrobial stewardship programs (ASPs) are advised to audit antimicrobial consumption as a metric to feedback to clinicians. However, many ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We evaluated the impact of the dashboard deployment that displays these metrics and its acceptance among ASP members and antimicrobial prescribers. Materials/methods: We conducted semistructured interviews of ASP stewards and antimicrobial prescribers before and after implementation of a web-based ASP information dashboard (Fig. 1) implemented in the VA Midwest Health Care Network (VISN23). The dashboard provides risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility. Risk-adjusted benchmarking was based on an observed-to-expected comparison of antimicrobial days of therapy at each facility, after adjusting for differences in patient case mix and facility-level variables. Respondents were asked to evaluate several aspects of the dashboard, including its ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and advantages compared to other ASP monitoring systems. All interviews were digitally recorded and transcribed verbatim. The analysis was conducted using MaxQDA 2020.4 and the Consolidated Framework for Implementation Research (CFIR) constructs. Results: We completed 4 preimplementation interviews and 11 postimplementation interviews with ASP champions and antimicrobial prescribers from 6 medical centers. We derived 4 key themes from the data that map onto CFIR constructs. These themes were interconnected so that implementation of the dashboard (ie, adapting and adopting) was influenced by respondents’ perception of a facility’s size, patient population, and priority placed on stewardship (ie, structural and cultural context), the availability of dedicated stewardship staff and training needed to implement the dashboard (ie, resources needed), and how the dashboard compared to established stewardship activities (ie, relative advantage). ASP champions and antimicrobial prescribers indicated that dashboard metrics were useful for identifying antimicrobial usage and for comparing metrics among similar facilities. Respondents also specified barriers to acceptance of the risk-adjusted metric, such as disagreement regarding how antimicrobials were grouped by the current NHSN protocol, uncertainty of factors involved in risk adjustments, and difficulty developing a clear interpretation of hospital rankings. Conclusions: Given the limited resources for antimicrobial stewardship personnel, automated, risk-adjusted, antimicrobial-use dashboards provided by ASPs are an attractive method to both facilitate compliance and improve efficiency. To increase the uptake of surveillance systems in antimicrobial stewardship, our study highlights the need for clear descriptions of methods and metrics.Funding: NoneDisclosures: None

A Retrospective Review of the Timing of Glasgow Coma Scale Documentation in a Trauma Database: Implications for Patient Care, Research, and Performance Metrics

The Glasgow Coma Scale (GCS) is intended to be an objective, reliable measure of a patient's mental status. It is included as a metric for trauma registries, having implications for performance metrics and research. Our study compared the GCS recorded in the trauma registry (GCS-1) with that recorded in the neurosurgery consultation (GCS-2). This retrospective review compared GCS-1 with GCS-2. The Trauma Injury Severity Score (TRISS) method was used to calculate probability of survival (POS) for patients using both GCS-1 and GCS-2. GCS-1 score significantly differed from GCS-2 score (6.69 vs. 7.84, ± 2.553; P < 0.001). There were 172 patients (37.55%) with a GCS-1 score of 3 and 87 (19.00%) with a GCS-2 score of 3 (χ2P < 0.001). The POS calculated using TRISS methodology with GCS-1 (POS-1) was 74.7% ± 26.6% compared with GCS-2 (POS-2), which was 79.3% ± 24.4%. There was a statistically significant difference in the means of POS-2 and POS-2 (P < 0.001). The actual observed survival for the cohort was 71.0% (325/458). The immediate GCS score recorded on patient arrival after trauma differs significantly from the GCS score recorded at later times. This finding significantly altered the probability of survival as calculated by the TRISS methodology. This situation could have profound effects on risk-adjusted benchmarking, assessments of quality of care, and injury severity stratification for research. More studies into the optimal timing of GCS score recording or changes in GCS score and their impact on survival are warranted.

34 Using a National Burn Registry to Develop a Model for Risk-adjusted Length of Stay Benchmarking

IntroductionLength of stay (LOS) is a frequently reported outcome after a burn injury. Previous literature estimates LOS at 1 day per % total burn surface area (TBSA) but this varies considerably across patients & centers. LOS benchmarking will benefit individual burn centers as a way to measure their performance & set expectations for patients. We sought to create a nationwide, risk-adjusted model to allow for LOS benchmarking based on data from a national burn registry.MethodsUsing data from a national burn registry, we queried admissions from 7/2015-6/2020 & identified 126,129 records with LOS data reported by 103 centers. We selected 23 predictor variables on the basis of completeness (min. 75% required) & clinical significance. Missing data were multiply imputed with a Bayesian Ridge Regression estimator. All statistics were calculated in Python using Numpy & Scikit-Learn libraries. Comparisons of unpenalized linear regression & Gradient boosted (CatBoost) regressor models were performed by measuring the R2 & concordance correlation coefficient (CCC) on the application of the model to the test dataset. The CatBoost model applied to bootstrapped versions of the entire dataset was then used to calculate O/E ratios for individual burn centers. Confidence intervals (CI) for O/E ratios were calculated using a normal distribution parametric model. Analyses were run on 3 cohorts: all patients, 10-20% TBSA, >20% TBSA.ResultsThe CatBoost model outperformed the linear regression model with a test R2 of 0.68 & CCC of 0.81 compared to the regression model with R2=0.52, CCC=0.70. The CatBoost was also less biased for higher & lower LOS durations. Due to the CatBoost model’s superiority in predicting the outcome, this model alone was used for O/E ratio calculations. The O/E ratio data from the model for all 3 cohorts are shown in Figure 1.ConclusionsGradient boosted regression models provided greater model performance than traditional regression analysis. Using national burn data, we can predict LOS across contributing burn centers while accounting for patient & center characteristics, producing more meaningful O/E ratios. These models provide a risk-adjusted LOS benchmarking using a robust data source, the first of its kind, for burn centers.

Automated Nationwide Benchmarking Dashboard for Antimicrobial Stewardship Programs within the Veterans’ Health Administration

Group Name: VHA Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance (CASPAR) Background: Antimicrobial stewardship programs (ASPs) are advised to measure antimicrobial consumption as a metric for audit and feedback. However, most ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We created a system that automatically extracts antimicrobial use data and patient-level factors for risk-adjustment and a dashboard to present risk-adjusted benchmarking metrics for ASP within the Veterans’ Health Administration (VHA). Methods: We built a system to extract patient-level data for antimicrobial use, procedures, demographics, and comorbidities for acute inpatient and long-term care units at all VHA hospitals utilizing the VHA’s Corporate Data Warehouse (CDW). We built baseline negative binomial regression models to perform risk-adjustments based on patient- and unit-level factors using records dated between October 2016 and September 2018. These models were then leveraged both retrospectively and prospectively to calculate observed-to-expected ratios of antimicrobial use for each hospital and for specific units within each hospital. Data transformation and applications of risk-adjustment models were automatically performed within the CDW database server, followed by monthly scheduled data transfer from the CDW to the Microsoft Power BI server for interactive data visualization. Frontline antimicrobial stewards at 10 VHA hospitals participated in the project as pilot users. Results: Separate baseline risk-adjustment models to predict days of therapy (DOT) for all antibacterial agents were created for acute-care and long-term care units based on 15,941,972 patient days and 3,011,788 DOT between October 2016 and September 2018 at 134 VHA hospitals. Risk adjustment models include month, unit types (eg, intensive care unit [ICU] vs non-ICU for acute care), specialty, age, gender, comorbidities (50 and 30 factors for acute care and long-term care, respectively), and preceding procedures (45 and 24 procedures for acute care and long-term care, respectively). We created additional models for each antimicrobial category based on National Healthcare Safety Network definitions. For each hospital, risk-adjusted benchmarking metrics and a monthly ranking within the VHA system were visualized and presented to end users through the dashboard (an example screenshot in Figure 1). Conclusions: Developing an automated surveillance system for antimicrobial consumption and risk-adjustment benchmarking using an electronic medical record data warehouse is feasible and can potentially provide valuable tools for ASPs, especially at hospitals with no or limited local informatics expertise. Future efforts will evaluate the effectiveness of dashboards in these settings.Funding: NoDisclosures: None

Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction.

We aim to define a set of terms for common free flap complications with evidence-based descriptions. Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N=11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.

Engineering lemons

Recent complex financial products sold to households contradict the basic premise of canonical innovation theories: Financial innovation benefits its adopters. In my 2006–2015 sample of over 28,000 yield enhancement products (YEP), the securities offer attractive yields but negative returns. The products lose money both ex ante and ex post due to their embedded fees. On average, YEPs charge 6–7% in annual fees and subsequently lose 6–7% relative to risk-adjusted benchmarks. Simple and cheap combinations of listed options often statewise dominate YEPs. Competition, disclosure, or learning do not eliminate this inferior financial innovation over my sample period.

Maximizing donors' gifts: A comparison of actual and expected solid organ yield among VCA donors.

Vascularized Composite Allograft (VCA) transplantation provides life-changing transplants, but VCA adds complexity to the donation process and timing, possibly impeding solid organ donation. Expanding upon descriptive analyses, this study examines risk-adjusted predictions versus the observed number of organs donated by VCA donors. Our cohort included VCA donors in the United States during January 1, 2008-December 31, 2017 (n=51), using OPTN Deceased Donor Registration Form data and the Scientific Registry of Transplant Recipients (SRTR) donor yield models to calculate observed-to-expected (O:E) yield ratios. Almost all VCA donors' livers (48/51; 94.1%) and kidneys (92/102; 90.2%) were transplanted, with fewer hearts (28/51; 54.9%), lungs (46/102; 45.1%), pancreata (15/51; 29.4%), and intestines (3/51; 5.9%) transplanted. O:E ratios for overall organ yield were slightly greater than expected for VCA donors (1.10; 95% CI: 1.02-1.17). Liver (1.17: 1.08-1.27) and lung yields (1.38: 1.07-1.68) were both greater than expected, while kidney, heart, and pancreas yields were similar to expected. Across VCA types, bilateral upper limb and abdominal wall donors had better-than-expected yields while uterus, face, and unilateral upper limb donors all had similar-to-expected yields. Solid organ yield among VCA donors was as good or better than predicted, suggesting that VCA donation does not compromise recovery and transplantation of lifesaving organs.

Performance and Market Maturity in Mutual Funds: Is Real Estate Different?

Despite the lack of convincing evidence that active investment fund managers add value, the number of actively-managed US mutual funds has increased substantially over the last 25 years. While non-sector diversified mutual funds have received much attention, sector funds, except real estate mutual funds (REMFs), have not. In this paper, we provide new and more robust evidence on the performance of active REMFs compared to all actively managed mutual funds. We use the Carhart four-factor model with an additional liquidity factor as a risk-adjusted benchmark. We use wild bootstrap methods to deal with small samples, non-normality and heteroscedasticity, and we control for the false discovery of significant results. For portfolios of fund types, we find evidence of both significant outperformance and underperformance, net of fees, during 1992-2016. We consider non-overlapping five-year and three-year periods and find very limited evidence of persistent outperformance. For individual funds, we find that, for both sector and diversified funds, net of fees, only 0.79% are skilled. We find persistence in skills for only two individual fund managers of diversified funds. We investigate the effects of the outsourcing of management and of team versus individual management. Outsourcing has no effect on performance of non-RE sector funds but, for cap-based funds and style-based funds, it has a negative effect. There is some evidence that this may also be true for REMFs. Team management has no effect for any types of funds. Overall, we conclude that REMFs are generally no different from other sector funds.

Scale and Skill in Mutual Fund Management: Evidence from Norway

Using a sample free of survivorship bias and several risk-adjusted performance benchmarks to identify effects of scale on mutual fund performance in the Norwegian market, I find mixed evidence that both large and small funds underperform as against the middle-sized funds in the period 2005-2018. Controlling for relevant factors in panel data regressions, I find that, on average, performance worsens with an increase in size while giving support to initial findings of nonlinearity. The relationship is most robust after 2013 and seems to be affected by competition in the market as well as fund inflows. I do not find any empirical evidence to support the liquidity hypothesis.

Risk-adjusted benchmarks in laparoscopic liver surgery in a national cohort.

This study aimed to assess the best achievable outcomes in laparoscopic liver resection (LLR) after risk adjustment based on surgical technical difficulty using a national registry. LLRs registered in the Italian Group of Minimally Invasive Liver Surgery registry from November 2014 to March 2018 were considered. Benchmarks were calculated according to the Achievable Benchmark of Care (ABC™). LLRs at each centre were divided into three clusters (groups I, II and III) based on the Kawaguchi classification. ABCs for overall and major morbidity were calculated in each cluster. Multivariable analysis was used to identify independent risk factors for overall and major morbidity. Significant variables were used in further risk adjustment. A total of 1752 of 2263 patients fulfilled the inclusion criteria: 1096 (62·6 per cent) in group I, 435 (24·8 per cent) in group II and 221 (12·6 per cent) in group III. The ABCs for overall morbidity (7·8, 14·2 and 26·4 per cent for grades I, II and II respectively) and major morbidity (1·4, 2·2 and 5·7 per cent) increased with the difficulty of LLR. Multivariable analysis showed an increased risk of overall morbidity associated with multiple LLRs (odds ratio (OR) 1·35), simultaneous intestinal resection (OR 3·76) and cirrhosis (OR 1·83), and an increased risk of major morbidity with intestinal resection (OR 4·61). ABCs for overall and major morbidity were 14·4 and 3·2 per cent respectively for multiple LLRs, 30 and 11·1 per cent for intestinal resection, and 14·9 and 4·8 per cent for cirrhosis. Overall morbidity benchmarks for LLR ranged from 7·8 to 26·4 per cent, and those for major morbidity from 1·4 to 5·7 per cent, depending on complexity. Benchmark values should be adjusted according to multiple LLRs or simultaneous intestinal resection and cirrhosis.

574. Reporting of Vancomycin-Resistant Enterococcus Bacteremia among National Healthcare Safety Network Acute Care Hospitals

BackgroundThe National Healthcare Safety Network’s (NHSN’s) Multidrug-resistant Organism/Clostridioides difficile (MDRO/CDI) Module serves as a surveillance platform for tracking antibiotic-resistant laboratory-identified (LabID) organisms. LabID event surveillance, which does not require submission of clinical data to NHSN, provides proxy measures for MDRO burden. While surveillance of some organisms is federally mandated, these requirements do not extend to vancomycin-resistant Enterococcus (VRE). We sought to describe the extent of acute care hospital (ACH) participation in NHSN VRE surveillance and identify facility-level factors associated with VRE bacteremia. These could explain differences in VRE incidence and be used in preparation for a national risk-adjusted benchmark.MethodsACHs that reported at least one month of facility-wide inpatient (FacWideIN) VRE bacteremia LabID Event data to NHSN in 2017 were included in the analysis. LabID events were categorized as healthcare facility-onset (HO), defined as a laboratory result for a specimen collected ≥4 days after admission, or community-onset (CO), defined as a specimen collected < 4 days after admission. Monthly patient day and admission denominators were used to calculate FacWideIN HO incidence and CO prevalence rates. Univariate analyses were performed on facility-level factors from NHSN’s annual hospital survey to assess their relationship with HO VRE bacteremia.ResultsA total of 544 HO VRE bacteremia events were reported by 498 hospitals in 37 states. About 67% of reporting hospitals were located in California. The national rate of HO VRE bacteremia was 0.27 per 10,000 patient-days and the CO VRE bacteremia rate was 0.58 per 10,000 admissions. Major medical school affiliation, hospital type, larger number of beds and ICU beds, longer average length of stay and the presence of an oncology unit were significantly associated with HO VRE bacteremia (Table 1).ConclusionBased on the VRE data reported to NHSN, certain facility-level factors may contribute to a higher incidence of HO VRE bacteremia. Future analyses can allow us to determine whether these factors are independently associated with VRE. Risk-adjusted surveillance data can help guide facilities and states to compare their burden of VRE to a national benchmark. Disclosures All authors: No reported disclosures.