Risk-adjusted Outcomes Research Articles

Comparable Outcomes for Transcarotid and Transfemoral Transcatheter Aortic Valve Replacement at a High Volume US Center

With continued growth of transcatheter aortic valve replacement (TAVR), safe alternative access remains important for patients without adequate transfemoral (TF) access. Registry-based outcomes with transcarotid (TC) TAVR are favorable compared to transapical or transaxillary/subclavian, but TC vs TF comparisons have not been made. Our objective was to compare outcomes between TF and TC access routes for TAVR at a high-volume United States center. Methods: We retrospectively evaluated all TF and TC TAVR procedures from June 11, 2014 (first TC case) through December 31, 2019. The primary outcomes were 30-day stroke and 30-day mortality. Secondary outcomes were 1-year stroke, 1-year survival, and 30-day and 1-year life-threatening/major bleeding, vascular complications, and myocardial infarction. Propensity score weighted (PSW) models were used to compare risk-adjusted TF and TC outcomes. Of 1,465 TAVR procedures, 1319 (90%) were TF and 146 (10%) were TC. Procedure time and length of stay did not differ between groups. Unadjusted 30-day stroke (TF = 2.0%, TC = 2.7%, P = 0.536) and mortality (TF = 2.1%, TC = 2.7%, P = 0.629) were similar between groups. PSW 30-day stroke (odds ratio (OR) (95% confidence interval (CI)) = 0.8 (0.2-2.8)) and mortality (OR (95% CI) = 0.8 (0.2-3.0)) were similar between groups. Unadjusted and PSW 30-day major/life threatening bleeding, major vascular complications, and myocardial infarction did not differ between groups. Survival at one year was 90% (88%-92%) for TF patients and 87% (81%-93%) for TC patients (unadjusted P = 0.28, PSW hazard ratio = 1.0 (0.6-1.7)). Transcarotid TAVR is associated with similar outcomes compared to transfemoral TAVR at an experienced, high-volume center.

Enhanced Recovery After Surgery, Lean, and claims-based quality databases: how does it all make sense?

Healthcare is rapidly evolving toward value-focused objectives, integrating outcomes and cost instead of simply volume. Concepts pertaining to Enhanced Recovery After Surgery (ERAS), Lean, and claims-based risk-adjusted databases can be used to optimize value, but the application of Lean principles and risk-adjusted outcomes is poorly described in perioperative medicine in perioperative medicine. Lean management and process optimization tools allow the consistent application of a perioperative medical framework of ERAS to improve outcomes. Vizient risk-stratified outcomes are often used by hospitals to measure and compare quality. Understanding administrative databases and Lean concepts for change management will allow the perioperative physician to better align medical concepts with health system tools for improving quality and reducing cost.

Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions.

To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

Association of Race, Socioeconomic Factors, and Treatment Characteristics With Overall Survival in Patients With Limited-Stage Small Cell Lung Cancer

It has been established that disparities in race and socioeconomic status are associated with outcomes of non-small cell lung cancer. However, it remains unknown whether this extends to stage I, II, or III small cell lung cancer (SCLC), or limited-stage SCLC (L-SCLC). To investigate the associations of race, socioeconomic factors, and treatment characteristics with survival among patients with L-SCLC. Demographic information for patients with L-SCLC diagnosed between 2004 and 2014 was obtained from the National Cancer Database. The follow-up end point is death or last follow-up (date of last contact). Patients were divided into 5 mutually exclusive cohorts by race. Data analysis was performed in October 2019. Cox proportional hazards models were used to calculate univariable and multivariable models. Multivariable analyses were conducted to assess the associations of race and socioeconomic factors with risk-adjusted outcomes. Overall survival between groups was depicted by Kaplan-Meier curves. Of 72 409 patients analyzed (median [range] age, 67.0 [23.0-90.0] years), 40 289 (55.6%) were women. The distribution of disease stage was 10 619 patients (14.7%) with stage I disease, 7689 patients (10.6%) with stage II disease, and 54 101 patients (74.7%) with stage III disease. The median (range) duration of follow-up was 8.2 (2.4-15.8) months. Compared with White patients, the hazard of death decreased to 0.92 (95% CI, 0.89-0.95; P < .001) for African American patients and 0.83 (95% CI, 0.77-0.91; P < .001) for Asian patients. The difference in median survival among different racial groups was significant only among those with stage III SCLC. Other factors associated with better survival were female sex, high income, high education, private insurance, diagnostic confirmation by positive cytological analysis, increase in number of sampled regional lymph nodes, and earlier stage at diagnosis. This analysis highlights disparities in race and socioeconomic factors associated with outcomes of L-SCLC. Racial minorities, including African American and Asian patients, have better survival than White patients for L-SCLC after adjustment for sociodemographic factors.

Availability of a final abdominopelvic CT report before emergency department disposition: risk-adjusted outcomes in patients with abdominal pain.

To determine whether availability of a final radiologist report versus an experienced senior resident preliminary report prior to disposition affects major care outcomes in emergency department (ED) patient presenting with abdominal pain undergoing abdominopelvic CT. This single-institution, IRB-approved, HIPAA-compliant retrospective cohort study included 5019 ED patients with abdominal pain undergoing abdominopelvic CT from October 2015 to April 2019. Patients were categorized as being dispositioned after either an experienced senior resident preliminary report (i.e., overnight model) or the final attending radiologist interpretation (i.e., daytime model) of the CT was available. Multivariable regression models were built accounting for demographic data, clinical factors (vital signs, ED triage score, laboratory data), and disposition timing to analyze the impact on four important patient outcomes: inpatient admission (primary outcome), readmission (within 30days), second operation within 30days, and death. In the setting of an available experienced senior resident preliminary report, timing of the final radiologist report (before vs. after disposition) was not a significant multivariable predictor of inpatient admission (p = 0.63), readmission within 30days (p = 0.66), second operation within 30days (p = 0.09), or death (p = 0.63). Unadjusted event rates for overnight vs daytime reports, respectively, were 37.2% vs. 38.0% (inpatient admission), 15.9% vs. 16.5% (30-day readmission), 0.65% vs. 0.3% (second operation within 30days), and 0.85% vs. 1.3% (death). Given the presence of an experienced senior resident preliminary report, availability of a final radiology report prior to ED disposition did not affect four major clinical care outcomes of patients with abdominal pain undergoing abdominopelvic CT.

Evaluating Quality in Adult Cardiac Surgery.

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.

User-Generated Physician Ratings and Their Effects on Patients' Physician Choices: Evidence from Yelp

We examine whether user-generated physician ratings from online sources signal physician quality information and affect patients' physician choices. We collect physician rating and review data from Yelp, a leading online physician rating platform, and match the rating data with Medicare claims data. First, we empirically examine information included in physician reviews by using machine learning algorithms and Amazon Mechanical Turk. We find that although reviews primarily describe physicians' service quality and interpersonal skills, ratings are positively associated with important conventional measures of clinical quality, including physicians' credentials, their adherence to clinical guidelines, and their patients' risk-adjusted health outcomes. To examine the effects of online ratings on patients' physician choices, we examine the effects of ratings on patient flow, measured by physicians' patient revenue and patient volume. By instrumenting for physicians' ratings with reviewers' leniency (or harshness) in rating other businesses, we find that a 1-star increase in a physician's average rating increases physicians' patient revenue and volume by 1.9% and 1.2%, respectively. Overall, we find that online physician rating platforms can promote efficiency by disseminating important quality information to patients and directing patients to higher-quality physicians.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon. Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons. We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days. We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01). Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Center-level CABG and valve operative outcomes and volume-outcome relationships in New York State.

We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Abstract 14971: Impact of Medicare Diagnosis Code Expansion and Inclusion of Outpatient Data on Risk-adjusted 30-day Mortality and Readmission Rates After Acute Myocardial Infarction

Introduction: In January 2011, the Center for Medicare and Medicaid Services increased the number of billing codes allowed per admission from 9 to 25. This caused an artificial increase in comorbidity burdens. Some have argued including outpatient data mitigates this problem. The aim of this study was to explore the impact of diagnosis code expansion, using inpatient and inpatient+outpatient data and evaluate potential solutions for conducting longitudinal studies of 30-day risk-adjusted outcome rates after acute myocardial infarction (AMI). Hypothesis: Limiting diagnosis codes and including outpatient data would produce the most stable estimates of risk-adjusted outcomes over time. Methods: We used 100% Medicare data to create a cohort of beneficiaries with AMI between 2008 and 2013. We used 4 methods to calculate the hierarchical condition categories/patient (HCC/pt) necessary for risk adjustment: 1) inpatient-only data, limited codes after 2011; 2) inpatient-only data, unlimited codes; 3) inpatient+ outpatient data, limited codes; 4) inpatient+outpatient data, unlimited codes. Results: Using inpatient-only data, expanding diagnosis codes increased the average HCC/pt by +0.23 HCC/pt. Using inpatient+outpatient data, the average increase was only +0.11 HCC/pt. (relatively 109% less, Figure A ). Between 2009-2013, AMI mortality was flat while readmissions declined ( Figure B ). For mortality, all 4 methods produced estimates that were, on average, +0.7% higher than unadjusted (raw) rates. For readmission, the closest to unadjusted and most stable over time was inpatient+outpatient data with limited codes. Conclusion: For studies that span January 2011, diagnosis codes should be limited to 9 after 2011 when using inpatient or combined inpatient and outpatient data.

Abstract 15874: An Ischaemia Time of Greater Than 6 Hours is Associated With Deleterious Outcomes in Pediatric Heart Transplantation

Introduction: The shortage of available donor organs means we must re-consider our current policies on donor selection. There is a broad variation in practice between centers as to the acceptable limit to ischaemia time (IT) in pediatric cardiac transplantation, with no recommendations in international guidelines. Hypothesis: We hypothesised that a prolonged ischaemia time was not associated with impaired post-transplant outcomes. Methods: Data from the Pediatric Heart Transplantation Society was analysed for all pediatric patients receiving heart transplants (Jan 1993 - June 2019). Transplants were separated into 5 categories depending on the IT (hours): &lt; 2.4, 2.5-3.4, 3.5-4.4, 4.5-6.0, &gt;6. Risk-adjusted outcomes were assessed by multivariable analysis, adjusting for donor, recipient, and peri-operative characteristics. Results: Data for 6,903 transplants were assessed (IT &lt; 2.4 in 980, 2.5-3.4 in 2032, 3.5-4.4 in 2310, 4.5-6.0 in 1162, &gt;6 in 281). In univariate analysis, increasing IT was associated with reduced 1-year survival (90.1%, 87.7% and 84.6%; p&lt;0.001) for the 3.5-4.4, 4.5-6.0 and &gt;6 groups, respectively. Similar findings, of a deleterious association with prolonged IT, were observed for freedom from infection (73.0%, 66.8% and 56.4%; p&lt;0.001), freedom from first rejection (67.4%, 62.6% and 61.0%; p = 0.01) and freedom from haemodynamically compromising rejection (89.1%, 85.4% and 85.3%; p=0.004) at 1-year. No significant differences in the risk of malignancy (p=0.2) and time to first CAV (p=0.08) between the IT groups were noted. We separately analysed the risk of graft failure by multiphase hazards modelling. In adjusted analysis, increasing IT was found to be a risk factor for graft failure (HR: 1.08, 95% CI: 1.00-1.16, p=0.04). Within this model, primary diagnosis was a predictor of the outcome (p&lt;0.001). Exploring this association, an IT of &gt; 6 hours was associated with graft failure in cardiomyopathy (HR: 2.87, 95% CI: 1.34 - 6.15, p=0.007), but not congenital heart disease patients. Conclusions: In this large multi-centre cohort study, we found a deleterious association between prolonged IT and post-transplant outcomes. We recommend that an IT greater than 6 hours should be avoided in pediatric cardiac transplantation.

ASO Author Reflections: A Reductionist's Approach to Risk-Adjusted Predictions and Outcomes Assessment: Less is More.

ASO Author Reflections: A Reductionist's Approach to Risk-Adjusted Predictions and Outcomes Assessment: Less is More.

Association Between Cardiac Surgeons’ Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers

More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear. To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded. Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes. A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG. In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.

Development of a Clinical Prediction Model for In‐hospital Mortality from the South African Cohort of the African Surgical Outcomes Study

Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827-0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.

Utility of Routine Preoperative Laboratory Testing for Low-Risk Patients in Ambulatory Gynecologic Surgery

Study Objective To evaluate the utility of routine preoperative laboratory testing in low-risk patients undergoing ambulatory gynecologic surgery. Design The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried for low-risk patients who underwent elective, ambulatory gynecologic surgery from 2015-2018. Setting The ACS NSQIP database is a validated, risk-adjusted surgical outcomes database that prospectively collects data from participating institutions nationally. Patients or Participants Low-risk patients selected for inclusion in this study were defined as being American Society of Anesthesiologists (ASA) class 1 or 2. This included 19,885 patients. Interventions Patient characteristics, comorbidities, and NSQIP-defined complications were compared between those with and without preoperative laboratory testing. Preoperative laboratory testing was defined as chemistry, hematology, coagulation, or liver function studies obtained within 30 days preoperatively. Measurements and Main Results Of 19,885 patients studied, 14,258 (71.8%) received preoperative laboratory testing, with at least one abnormal test identified in 4,053 (28.4%) patients. There was no statistically significant difference in overall postoperative complication rate when comparing patients who received preoperative laboratory testing with those who did not (2.5% vs. 2.2%, p=0.30). Additionally, there was no statistically significant difference in wound complications (1.0% vs. 1.0% p=0.78), major complications (1.0% vs. 0.8% p=0.11), unplanned return to the operating room (0.1% vs. 0.2%, p=0.40), unplanned readmission (0.7% vs. 0.5% p=0.10), or overall morbidity (2.1% vs. 1.9% p=0.38). Chi-squared analyses were performed to compare categorical variables. Continuous variables were compared using unpaired t-tests. Conclusion Preoperative laboratory testing continues to be performed in the majority of low-risk patients undergoing ambulatory gynecologic surgery despite evidence and guidelines that do not recommend this practice. However, there was no difference in surgical outcomes between patients who did and did not receive preoperative laboratory testing. Postoperative complications are infrequent in this patient population. These results suggest that preoperative laboratory testing should be used more judiciously in low-risk patients undergoing ambulatory gynecologic surgery. To evaluate the utility of routine preoperative laboratory testing in low-risk patients undergoing ambulatory gynecologic surgery. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried for low-risk patients who underwent elective, ambulatory gynecologic surgery from 2015-2018. The ACS NSQIP database is a validated, risk-adjusted surgical outcomes database that prospectively collects data from participating institutions nationally. Low-risk patients selected for inclusion in this study were defined as being American Society of Anesthesiologists (ASA) class 1 or 2. This included 19,885 patients. Patient characteristics, comorbidities, and NSQIP-defined complications were compared between those with and without preoperative laboratory testing. Preoperative laboratory testing was defined as chemistry, hematology, coagulation, or liver function studies obtained within 30 days preoperatively. Of 19,885 patients studied, 14,258 (71.8%) received preoperative laboratory testing, with at least one abnormal test identified in 4,053 (28.4%) patients. There was no statistically significant difference in overall postoperative complication rate when comparing patients who received preoperative laboratory testing with those who did not (2.5% vs. 2.2%, p=0.30). Additionally, there was no statistically significant difference in wound complications (1.0% vs. 1.0% p=0.78), major complications (1.0% vs. 0.8% p=0.11), unplanned return to the operating room (0.1% vs. 0.2%, p=0.40), unplanned readmission (0.7% vs. 0.5% p=0.10), or overall morbidity (2.1% vs. 1.9% p=0.38). Chi-squared analyses were performed to compare categorical variables. Continuous variables were compared using unpaired t-tests. Preoperative laboratory testing continues to be performed in the majority of low-risk patients undergoing ambulatory gynecologic surgery despite evidence and guidelines that do not recommend this practice. However, there was no difference in surgical outcomes between patients who did and did not receive preoperative laboratory testing. Postoperative complications are infrequent in this patient population. These results suggest that preoperative laboratory testing should be used more judiciously in low-risk patients undergoing ambulatory gynecologic surgery.

Association of Race and Ethnicity With Comorbidities and Survival Among Patients With COVID-19 at an Urban Medical Center in New York

As of May 11, 2020, there have been more than 290 000 deaths worldwide from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). Risk-adjusted differences in outcomes among patients of differing ethnicity and race categories are not well characterized. To investigate whether presenting comorbidities in patients with COVID-19 in New York City differed by race/ethnicity and whether case fatality rates varied among different ethnic and racial groups, controlling for presenting comorbidities and other risk factors. This cohort study included 5902 patients who presented for care to the Montefiore Medical Center, a large urban academic medical center in the Bronx, New York, between March 14 and April 15, 2020, and tested positive for SARS-CoV-2 on reverse transcription quantitative polymerase chain reaction assay. Final data collection was April 27, 2020. Patient characteristics, including self-identified ethnicity/race, age, sex, socioeconomic status, and medical comorbidities, were tabulated. Overall survival. Associations between patient demographic characteristics, comorbidities, and race/ethnicity were examined using χ2 tests, and the association with survival was assessed using univariable and multivariable Cox proportional hazards regression, based on time from positive COVID-19 test. Of 9268 patients who were tested, 5902 ethnically diverse patients (63.7%) had SARS-CoV-2. Of these, 3129 patients (53.0%) were women, and the median (interquartile range) age was 58 (44-71) years. A total of 918 patients (15.5%) died within the study time frame. Overall, 1905 patients (32.3%) identified as Hispanic; 1935 (32.8%), non-Hispanic Black; 509 (8.6%), non-Hispanic White; and 171 (2.9%), Asian; the death rates were 16.2% (309), 17.2% (333), 20.0% (102), and 17.0% (29), respectively (P = .25). Hispanic and non-Hispanic Black patients had a higher proportion of more than 2 medical comorbidities with 654 (34.3%) and 764 (39.5%), respectively, compared with 147 (28.9%) among non-Hispanic White patients (P < .001). Hispanic and non-Hispanic Black patients were also more likely to test positive for COVID-19 than White patients, with 1905 of 2919 Hispanic patients (65.3%), 1935 of 2823 non-Hispanic Black patients (68.5%), and 509 of 960 non-Hispanic White patients (53.0%) having positive test results for SARS-CoV-2 (P < .001). While controlling for age, sex, socioeconomic status and comorbidities, patients identifying as Hispanic (hazard ratio, 0.77; 95% CI, 0.61-0.98; P = .03) or non-Hispanic Black (hazard ratio, 0.69; 95% CI, 0.55-0.87; P = .002) had slightly improved survival compared with non-Hispanic White patients. In this cohort study of patients with COVID-19 who presented for care at the same urban medical center, non-Hispanic Black and Hispanic patients did not experience worse risk-adjusted outcomes compared with their White counterparts. This finding is important for understanding the observed population differences in mortality by race/ethnicity reported elsewhere.

Evaluating quality variation of emergency departments

Abstract Background Germany introduced a graduated system of emergency levels (0 non-participation; 1 for basic up to 3 for comprehensive infrastructure) to overcome various inefficiencies of hospital emergency care. For each level, detailed requirements must be met, however, the case volume of conditions treated in the levels is unclear. Moreover, the relationship between emergency level and outcomes needs evaluation to analyse if patients are directed to the most appropriate hospital. Methods We selected three major emergency conditions - Stroke, AMI and Hip fracture - and matched risk-adjusted outcome and process indicators on hospital level to the hospital respective emergency level. Descriptive statistics such as distribution and correlation are used to examine the allocation of cases to emergency levels and to analyse the effect of structural differences on health outcomes. Results We saw large variations in quality for all clinical conditions regardless of the emergency level. Hospitals with a small case number showed greater fragmentation; hospitals that did not meet the requirements nevertheless performed interventions for AMI and stroke. In detail, 30-day mortality of AMI shows high variation of quality results in level 1; for stroke it is underperformed with almost 10% in hospitals with level 0. Pre-operative LOS for hip fracture is above the acceptable average in any level (tolerance range ≤ 15%), and the ratio O/E in mortality is noticeable for 40% of hospitals with level 0. Conclusions Many cases are treated in low volume hospitals with wide quality variation and subpar results. Therefore, the definition of emergency levels should be integrated to emergency pathways which might help to direct patients to the most appropriate hospital. Moreover, many emergency symptoms are not captured by available quality metrics and current classification systems which shows that emergency service provision is to a large extent not covered by current measurement initiatives. Key messages Emergency service provision is fragmented and not related to emergency levels. Development of emergency quality indicators is needed.

Association Between Surgeon Technical Skills and Patient Outcomes

Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes. To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill. In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019. Colorectal and noncolorectal procedures. Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity. Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates. The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.

Impact of Operator Characteristics on Outcomes in Transcatheter Aortic Valve Replacement

Operator characteristics and outcome relationships have not been evaluated at the individual operator level. From New York State Department of Health Statewide Planning and Research Cooperative System, 5896 elective transfemoral transcatheter aortic valve replacement (TAVR) procedures performed by 161 operators between 2012 and 2016 were analyzed. We examined the following characteristics of the primary operator: specialty (surgery vs cardiology), sex, medical school location, experience of cardiology practice, interventional cardiology credentialing, past-year TAVR volume, and first year performing TAVR in New York State. The primary outcome was a composite of inhospital mortality, stroke, and acute myocardial infarction. After adjusting for patient and other provider characteristics, there was no significant difference in the risk of major events between surgeons and cardiologists in performing TAVR (3.4% vs 3.6%, P= .60), between male operators and female operators (P= .80), and between operators who graduated from a US medical school and operators educated outside the United States (3.4% vs 3.6%, P= .73). In the subgroup analysis, interventional cardiology credentialing was not significantly associated with the inhospital major events (odds ratio 1.03; 95% confidence interval, 0.56 to 1.88; P= .80). Primary operator specialty and other characteristics for TAVR were not associated with a difference in risk-adjusted inhospital outcomes. That may be due to the heart team model that allows proceduralists of different backgrounds to lend their expertise to the procedure.