Risk-adjusted Complication Rates Research Articles

Risk Adjustment in the California Joint Replacement Registry: Is Patient Complexity Accurately Assessed in Academic Versus Nonacademic Hospitals?

BackgroundWe sought to report on the differences in observed versus expected arthroplasty outcomes between academic and nonacademic hospitals in a large joint registry. We utilized the California Joint Replacement Registry’s data and risk adjustment model. MethodsObserved versus expected hip and knee arthroplasty complications were utilized to assess hospital and surgeon risk-adjusted complication rates (RACRs). Based on a hospital and surgeon RACR, each was assigned a performance rating (“worse,” “expected,” “better”). Associations between academic status and performance ratings, rates of individual complications, prevalence of risk factors associated with increased complication rates, and differences in complication rates were calculated. ResultsA higher percentage of academic providers had “worse” than expected ratings, whereas a higher percentage of nonacademic providers had “expected” and “better” than expected ratings (P = .011) based on the observed versus expected complication rates. There was a higher incidence of patients with congestive heart failure and an elevated American Society of Anesthesiologists classification in academic institutions (P = .0001). The complication rate was higher in academic institutions for all total knee arthroplasties (P < .0016). ConclusionsWe identified disparities in RACRs between nonacademic and academic institutions. This may reflect the difficulty of fully adjusting for medical risk and surgical complexity in a large arthroplasty database.

The Association Between Hospital Volume and Failure-to-rescue for Open Repairs of Juxtarenal Aneurysms

Higher-volume hospitals have lower mortality rates after open repairs of complex abdominal aortic aneurysms (AAAs). However, the clinical mechanisms underlying this association remain elusive. We assessed whether rates of postoperative complications versus failure to rescue (defined as death after a major postoperative complication) better explained lower mortality rates among higher-volume hospitals after open repairs of complex AAAs. Using the 2004 to 2018 Vascular Quality Initiative, we identified all patients who underwent open repairs of complex AAAs, where the proximal clamp site was above at least one renal artery. After dividing patients into quintiles by annual hospital volume, we compared risk-adjusted rates of 30-day postoperative mortality, complications, and failure to rescue between the lowest volume and highest volume hospitals. Multivariable logistic regressions adjusted for clinical and intraoperative factors (ie, proximal clamp site, ischemia time, iliac aneurysmal disease), and hospital clustering. We identified 3566 patients (median age, 71 years; 81% male; 92% Caucasian; median aneurysm size, 5.9 cm) undergoing open repairs of complex AAAs. The risk-adjusted mortality rate was 2.5 times greater among lower volume hospitals relative to higher volume hospitals (7.4% vs 3.0%; P < .01). While risk-adjusted complication rates were respectively similar (29.5% vs 26.9%; P = .06), risk-adjusted failure-to-rescue rates were 2.3 times greater among lower volume hospitals relative to their higher volume counterparts (6.3% vs 2.7%; P = .02) (Table). The most common postoperative complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with their specific rates of failure to rescue varying from 12% to 22%. Higher volume hospitals have lower mortality rates after open repairs of complex AAAs because they better “rescue” patients from complications, relative to their lower volume counterparts. Understanding the clinical mechanisms underlying this association, from macroscopic hospital factors to communication and culture, in addition to the regionalization of open repairs of complex AAAs, may improve patient outcomes.TableMultivariate logistic regressions assessing the association between hospital volume and all three outcomesHigh-volume hospitalsLow-volume hospitalsaOR (95%-CI)aP valueaMortality3.0%7.4%2.51 (1.42-4.42)<.01Complications27.1%29.2%1.31 (0.91-1.90)0.15Failure-to-rescue2.7%6.3%2.30 (1.16-4.57)0.02aAdjusted for hospital volume quintiles, patient age, gender, race, insurance, BMI, smoking history, aneurysm diameter, operative approach, intraoperative ischemia time, prior aortic surgery, presence of iliac aneurysms, comorbidities (COPD, CKD, heart disease, DM, PVD, carotid artery stenosis or endarterectomy) and hospital-level clustering. Reference: high-volume hospitals. Open table in a new tab

Patient Complications after Total Joint Arthroplasty: Does Surgeon Gender Matter?

Recent studies in general surgery and internal medicine have shown that female physicians may have improved morbidity and mortality compared with their male counterparts. In the field of orthopaedic surgery, little is known about the influence of surgeon gender on patient complications. This study investigates patient complications after hip and knee arthroplasty based on the gender of the treating surgeon. Using a risk-adjusted outcomes database of 100% Medicare data from a third party, an analysis of outcomes after primary hip and knee arthroplasty based on surgeon gender was performed. This data set, which provided risk-adjusted complication rates for each surgeon performing at least 20 primary knee or hip arthroplasties from 2009 to 2013, was matched with publically available Medicare data sets to determine surgeon gender, year of graduation, area of practice, and surgical volume. Confounding variables were controlled for in multivariate analysis. Of the 8,965 surgeons with identified gender, 187 (2.0%; 187 of 8,965) were identified as women and performed 21,216 arthroplasties (1.4%; 21,216 of 1,518,419). Overall, female surgeons averaged fewer arthroplasties (total knee arthroplasty: 87.0 versus 124.9 [P < 0.001]; total hip arthroplasty [THA]: 62.8 versus 78.8 [P = 0.02]) and were earlier in their practice (20.6 versus 25.0 years; P < 0.001) compared with their male counterparts. Male and female surgeons had similar adjusted complication rates for THA (2.78% versus 2.84%) and total knee arthroplasty (2.24% versus 2.26%). Multivariate analysis found that the predictors of increased complications were decreased surgeon volume, THA, increased surgeons' years in practice, and geographic region. Overall, female orthopaedic surgeons performed fewer arthroplasties and were earlier in their career. This, however, did not a have a negative impact on their surgical outcomes. Rather, complication rates were dependent on surgeon volume, surgeon experience, and region. Level III-prognostic retrospective case-control study.

Factors Associated With Long Wait Times for Bariatric Surgery.

Despite its proven safety and efficacy, bariatric surgery is an underutilized therapy for severe obesity. Wait times for surgery are largely unexplored in the United States and may impact access to care. To determine the amount of time between initial bariatric surgery clinic visit and operative date and identify factors associated with longer wait times. A statewide clinical data registry was queried from 2006 to 2016 and 60,791 patients undergoing primary bariatric surgery were identified. Demographics, comorbidities, 30-day complications, and 1-year patient-reported outcomes were compared between shortest and longest wait time quartiles. Analyses were performed using Chi-square, t-test, and logistic regression. Median wait times for bariatric surgery increased from 86 to 159 days during the study period. Median wait times were ≤67 days for the shortest wait time quartile and ≥204 days for the longest wait time quartile. Factors independently associated with longer wait times included Medicaid insurance [odds ratio (OR) 3.02; 95% confidence interval (CI): 2.58-3.53], sleep apnea (OR 1.49; 95% CI: 1.41-1.58), psychological disorder (OR 1.25; 95% CI: 1.18-1.32), hyperlipidemia (OR 1.21; 95% CI: 1.14-1.28), smoking history (OR 1.11; 95% CI: 1.05-1.17), and white race (OR 0.665; 95% CI: 0.614-0.720). Preoperative weight loss, risk adjusted complication rates, postoperative self-reported weight loss, and comorbidity remission were similar between groups. Over the past decade, eligible patients are experiencing longer wait times when pursuing bariatric surgery. Complex patients with Medicaid insurance are experiencing the longest delay despite similar outcomes and preoperative weight loss. Policies that delay surgery should be re-examined.

Impact of hospital volume on patient safety indicators and failure to rescue following open aortic aneurysm repair

ObjectiveFailure to rescue (FTR), a patient safety indicator (PSI) defined, codified, and adjudicated by the Agency for Healthcare Research and Quality, is classified as a preventable inpatient death following major complications. FTR has been reported to be a significant driver of postoperative mortality after open abdominal aortic aneurysm (OAAA) repair. The association between hospital volume (HV) and mortality is well known; however, the mechanisms responsible for these improved outcomes and relative contribution to observed interhospital variation is poorly understood. Similarly, HV influence on specific complications predictive of FTR is unknown; therefore, we sought to determine how HV influences risk and contributes to interhospital variation in PSI events leading to FTR and/or in-hospital mortality after OAAA repair. MethodsThe Vizient database (174 academic/nonacademic hospitals) was queried for all OAAA repairs (elective, n = 2827; nonelective, n = 1622) completed from 2012 to 2014. The primary endpoint was combined FTR and/or in-hospital 30-day mortality. Risk-adjusted rates of complications, Agency for Healthcare Research and Quality-designated PSIs, and FTR were determined. Additional modeling identified PSIs associated with FTR, whereas HV effects on PSIs and FTR were evaluated using mixed-effect models accounting for interhospital variation. Proportion of variation attributable to HV was estimated by contrasting hospital random effect variances in the presence/absence of volume effects. ResultsThe combined overall FTR/in-hospital 30-day mortality rate was 9.3% (n = 414). For elective and nonelective cases, the overall FTR and 30-day mortality rates were: FTR, 1.6%, 4.9%; and 30-day in-hospital mortality, 3.4%, 17.5%, respectively. HV significantly influenced FTR/30-day in-hospital mortality (P < .0001). FTR/30-day mortality odds for hospitals with 3-year volumes of 50, 100, 150, and 200 cases were 1.4, 2.0, 2.7, and 3.0 times lower, respectively, than hospitals performing ≤25 cases/3 years. The proportion of interhospital variation attributed to HV was greatest for FTR/30-day mortality (62%). Procedural volume accounted for 41% and 38% of interhospital variation in postoperative bleeding and myocardial infarction, respectively. Preoperative predictors of FTR included coagulopathy, arrhythmia (nonelective cases); congestive heart failure, obesity (elective cases); and age, neurological disease, hypertension, and valvular disease (all cases). ConclusionsOAAA FTR/30-day in-hospital mortality strongly correlated with annual case volume with higher volume centers having the lowest risk. Notably, HV accounted for a significant proportion of the observed variation in FTR and specific complications providing direct evidence for how the volume-outcome relationship may influence perioperative mortality. These findings can inform stakeholders to strategically enable them to implement processes of care directed at the most vulnerable patients that are designed to reduce the likelihood of preventable adverse events and death after OAAA repair. Furthermore, these results underscore the need to regionalize OAAA repair and potentially other complex operations, to HV centers because of their improved ability to rescue patients experiencing complications associated with postoperative mortality.

Surgeon variation in severity of reflux symptoms after sleeve gastrectomy.

Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. A validated reflux symptom survey was obtained at baseline and at 1year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study.

Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series.

To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP). The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs. A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32-0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63-0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71-0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10-1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16-1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64-1.96), P < 0.001]. Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended. Therapeutic Level III.

Understanding Disparities in Surgical Outcomes for Medicaid Beneficiaries.

Few studies have evaluated whether outcome disparities between Medicaid and private insurance beneficiaries are driven by the hospital at which the patient receives care. The purpose of this study was to evaluate the effect of the hospital on surgical outcomes in Medicaid beneficiaries. We identified 139,566 non-elderly Medicaid and private insurance beneficiaries undergoing general, vascular, or gynecological surgery between 2012 and 2017 using a statewide clinical registry in Michigan. We calculated risk-adjusted rates of complications, readmissions, emergency department (ED) visits, and post-acute care utilization using multivariable logistic regression, accounting for patient and procedural factors. We then evaluated whether, and to what extent, the hospital influenced outcome disparities between Medicaid and privately insured beneficiaries. Risk-adjusted rates for all outcomes were higher in Medicaid beneficiaries. For example, overall post-discharge ED visit rates were 14.3% (95% CI 13.7% to 14.9%) for Medicaid compared to 7.5% (95% CI 7.1% to 7.9%, P < 0.01) for private insurance beneficiaries. Hospital factors explained 3.9% of the observed difference in complication rates between Medicaid and private insurance beneficiaries. In contrast, hospital factors explained a greater proportion of the disparities in readmissions (30.6%), ED visits (33.0%), and post-acute care utilization (16.1%). Results were similar when restricting the study population to elective cases only. Hospital factors account for a significant proportion of the disparities in post-discharge resource utilization between Medicaid and private insurance beneficiaries. Policies aiming to improve the quality and equity of surgical care for Medicaid beneficiaries should focus on the post-discharge period.

Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-Based Study

BACKGROUND Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a master surgeon and 1 representing a surgeon-in-training. Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery

BackgroundThe relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality. MethodsA retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue). ResultsA total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16–1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51–2.09), 30-day readmission (RR 1.21 95% CI 1.06–1.39), 90-day mortality (RR, 1.29, 95% CI 1.01–1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14–1.97). ConclusionHighest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality.

Failure to Rescue and Mortality Following Resection of Intracranial Neoplasms

There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications. To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms. We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication). A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]). While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.

Surgeon leadership style and risk-adjusted patient outcomes.

There are many reasons to believe that surgeon personality traits and related leadership behaviors influence patient outcomes. For example, participation in continuing education, effective self-reflection, and openness to feedback are associated with certain personalities and may also lead to improvement in outcomes. In this context, we sought to determine if an individual surgeon's thinking and behavior traits correlate with patient level outcomes after bariatric surgery. Practicing surgeons from the Michigan Bariatric Surgery Collaborative (MBSC) were administered the Life Styles Inventory (LSI) assessment. The results of this assessment were then collapsed into three major styles that corresponded with particular patterns of an individual's thinking and behavior: constructive (achievement, self-actualizing, humanistic-encouraging, affiliative), passive/defensive (approval, conventional, dependent, avoidance), and aggressive/defensive (perfectionistic, competitive, power, oppositional). We compared patients level outcomes for surgeons in the lowest, middle, and highest quintiles for each style. We then used patient level risk-adjusted rates of complications after bariatric surgery to quantify the impact surgeon style on post-operative outcomes. We found that patients undergoing bariatric surgery performed by surgeons with high levels of constructive (achievement, self-actualizing, humanistic-encouraging, affiliative) and passive/defensive (approval, conventional, dependent, avoidance) styles had lower rates of adverse events compared with surgeons with low levels of the respective styles [High constructive: 14.7% (13.8-15.6%), low constructive: 17.7% (16.8-18.6%); high passive: 14.8% (13.4-16.1%), low passive: 18.7% (17.3-19.9%)]. Conversely, surgeons identified with high aggressive styles (perfectionistic, competitive, power, oppositional) had similar rates of post-operative adverse events compared with surgeons with low levels [high aggressive: 15.2% (14.3-16.1%), low aggressive: 14.9% (14.2-15.6%)]. Our analysis demonstrates that surgeons' leadership styles are correlated with surgical outcomes for individual patients. This finding underscores the need for professional development for surgeons to cultivate strengths in the constructive domains including intentional self-improvement, development of interpersonal skills, and the receptiveness to feedback.

Gender Disparities in Presentation, Management, and Outcomes of Acute Myocardial Infarction.

This review provides updates in gender disparities in the symptom profile, risk factors, quality and timeliness of guideline-based medical care, and clinical outcomes, including mortality, bleeding, and vascular complications, in patients with acute myocardial infarction (AMI). While AMI continues to be a leading cause of mortality in both men and women, significant gender differences exist in presentation, management, and outcomes. Women with AMI are older, suffer atypical symptoms, and more often present with HF and cardiogenic shock. Delays in medical care and hence longer ischemic times exist in women, partly due to decreased awareness and lack of symptom recognition. Women continue to be less likely to receive guideline-based pharmacological therapies and revascularization than men with AMI. While women suffer from significantly higher risk-adjusted rates of bleeding, vascular complications, and short-term mortality, the risk-adjusted rates of long-term mortality remain similar between men and women. Further investigations and efforts are needed to aggressively modify risk factors, reduce delays in care, and address the higher rates of adverse events seen in women with AMI. Significant sex disparities are prevalent in presentation, management, and outcomes of adults with AMI. Further investigations and efforts are needed to aggressively modify risk factors, reduce delays in care, and address the higher rates of adverse events seen in women with AMI.

The Association Between Provider Price and Complication Rates for Outpatient Surgical Services.

Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain. This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services. This is a retrospective cohort study. The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy. For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression. Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively. Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures. For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.

Hospital variation in mortality after emergent bowel resections: The role of failure-to-rescue

Hospital variation in failure-to-rescue (FTR) rates has partially explained nationwide differences in mortality after elective surgeries. To examine the role of FTR among emergency general surgery, we compared nationwide risk-adjusted mortality, complications, and FTR rates after emergent bowel resections. We identified patients who underwent emergent small or large bowel resections in the 2010 to 2011 Nationwide Inpatient Sample using the American Association for the Surgery of Trauma criteria. We then calculated risk-adjusted mortality rates for each hospital using multivariable logistic regressions and postestimation, which adjusted for patient age, sex, race and ethnicity, payer status, comorbidities, and hospital clustering. After excluding hospitals with fewer than 10 resections per year, we ranked the remaining hospitals by their risk-adjusted mortality rates and divided them into five quintiles. We compared both risk-adjusted complication rates and FTR rates between the top (lowest mortality) and bottom (highest mortality) quintiles. We identified 21,564 emergent bowel resections, weighted to 105,925 procedures nationwide. The bottom quintile of hospitals had an overall risk-adjusted mortality rate that was 10.9 times higher than that of the top quintile of hospitals (15.3% vs. 1.4%). While risk-adjusted complication rates were similarly high for both the bottom and the top quintiles of hospitals (22.5% vs. 15.7%), the risk-adjusted FTR rates were 10.8 times higher in the bottom quintile of hospitals relative to the top quintile of hospitals (33.4% vs. 3.1%). Using larger hospital volume thresholds yielded similar findings. Furthermore, large variations existed in complication-specific FTR rates (surgical site infection [6.6%] to myocardial infarction [29.4%]). Nationwide hospital variation in risk-adjusted mortality rates exist after emergent bowel resections. As complication rates were similar across hospitals, the significantly higher FTR rates at higher-mortality hospitals may drive this variation in mortality. System-level initiatives addressing the management of postoperative complications may improve patient care and reduce variation in outcomes. Prognostic and epidemiological study, level IV.

Local referral of pancreatectomy patients to improve surgical quality

Background: Referral of patients to high-quality hospitals (HQH) for complex procedures may improve outcomes. This is most feasible within small geographic areas, but access to specialized surgical procedures may be an implementation barrier. We sought to determine the availability of HQH performing pancreatectomy and the potential benefit of referral within small geographic areas. Methods: We identified pancreatectomy patients age ≥65 years in 2012–2013 Medicare claims data. Hospitals were grouped by risk-adjusted complication rates (HQH: best 2 quintiles; low- quality hospitals, LQH: worst 2 quintiles), and patients were risk-stratified by clinical factors. The geographic units of analysis were Metropolitan Statistical Areas (MSAs), each consisting of a population center ≥50,000 and the surrounding areas typical of commuting distances. Results: We analyzed data on 5579 patients treated at 646 hospitals. Of the 2402 patients (43%) who received care at 258 LQH, 74% had a HQH in their MSA. Patients treated at LQH were a median of 24 miles from a HQH. Patients treated in MSAs with only LQH were a median of 60 miles from a HQH in an adjacent MSA (Fig 1). A similar pattern was seen among high-risk patients; 71% were treated at LQH despite the presence of HQH in their MSA. High-risk patients treated at LQH were a median of 25 miles from a HQH. If high-risk patients traveled 25 miles to a HQH, post-pancreatectomy mortality would decrease from 7% to 4% (p = 0.0013) and morbidity would decrease by 48% (38% v 20%, p < 0.001). Conclusion: In small geographic areas pancreatectomy patients are often treated at LQH despite availability of HQH in the area or within an acceptable distance. Referral of patients, especially high-risk patients, to HQH within small geographic areas is a potentially effective strategy to improve outcomes of pancreatic surgery.

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study

To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate. A retrospective quasi-experimental study from June 2011 to October 2015. A tertiary cancer hospital in China. Patients diagnosed as non-small cell lung cancer who underwent curative resection. Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015. Three length of hospital stay indicators, four process performance indicators and one outcome indicator. ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators. The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

Comparative Evaluation of Gastroduodenostomy and Gastrojejunostomy for Stomach Reconstruction Following Partial Gastrectomy in Dogs

The present experimental study was aimed to perform partial gastrectomy through surgical excision the distal part of the stomach in dogs (approximately 1/5 stomach size), and then performing two types of reconstruction techniques: Gastroduodenostomy (Billroth I) and Gastrojejunostomy (Billroth II). The current experimental study was carried out on 10 apparently healthy mongrel dogs (7 males and 3 non-pregnant females), aging (8 months to 2 years old) and weighing (12 to 30 kg). Two types of surgical technique were used: A. Billroth I (Gastroduodenostomy): Partial gastroectomy with gastroduodenal anastomosis (5 dogs were used) B. Billroth II (Gastrojejunostomy): Partial gastroectomy with gastrojejunal anastomosis (5 dogs were used). All dogs recovered from anesthesia with no complications during the surgery and recovery. There was no evidence of wound infection. Dogs started to eat on Day 3 after surgery without any sign of regurgitation. No serious postoperative complications were observed. There were no signs of premature vasomotor disturbances, such as dizziness, weakness and alimentary disorders. One month after surgery radiographic findings cleared that there was neither stricture, narrowing, obstruction nor leakage at site of anastomosis in both groups. On conclusion; Both Billroth I and Billroth II might be considered as suitable approaches for reconstructing gastro-intestinal tract following partial gastrectomy in dogs with no particular difference in clinical and para-clinical parameters in dogs. Billroth I doesn’t change the normal anatomy and function of the digestive system as performed anastomosis of the stomach stump to the duodenum, it’s conductive to the digestion of food falling from the stomach into the intestine mixing with pancreatic, duodenal and biliary secretion while in Billroth II mixing process occurs in the jejunum. The time consumed during Billroth II operation was higher than Billroth I also the risk adjusted complication rate was also higher in Billroth II group. Billroth I method should be the first choice after a distal gastrectomy as long as the anatomic and oncological environment allows us to perform it.

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

Background.The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. Methods.We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). Results.A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. Conclusions.Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.