Ranking Hospitals on Surgical Mortality: The Importance of Reliability Adjustment

We examined the implications of reliability adjustment on hospital mortality with surgery.We used national Medicare data (2003–2006) for three surgical procedures: coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, and pancreatic resection.We conducted an observational study to evaluate the impact of reliability adjustment on hospital mortality rankings. Using hierarchical modeling, we adjusted hospital mortality for reliability using empirical Bayes techniques. We assessed the implication of this adjustment on the apparent variation across hospitals and the ability of historical hospital mortality rates (2003–2004) to forecast future mortality (2005–2006).The net effect of reliability adjustment was to greatly diminish apparent variation for all three operations. Reliability adjustment was also particularly important for identifying hospitals with the lowest future mortality. Without reliability adjustment, hospitals in the “best” quintile (2003–2004) with pancreatic resection had a mortality of 7.6 percent in 2005–2006; with reliability adjustment, the “best” hospital quintile had a mortality of 2.7 percent in 2005–2006. For AAA repair, reliability adjustment also improved the ability to identify hospitals with lower future mortality. For CABG, the benefits of reliability adjustment were limited to the lowest volume hospitals.Reliability adjustment results in more stable estimates of mortality that better forecast future performance. This statistical technique is crucial for helping patients select the best hospitals for specific procedures, particularly uncommon ones, and should be used for public reporting of hospital mortality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79322/1/HESR_1158_sm_appendix2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/79322/2/j.1475-6773.2010.01158.x.pd

Surgical treatment of breast cancer among the elderly in the United States

BACKGROUND: Breast-conserving therapy (BCT) has emerged as the preferred treatment for most women with early stage breast cancer. However, there is concern for underuse in the elderly, with previously documented low rates of BCT and large variations in practice patterns. The authors' purpose was to examine patterns and correlates of BCT for breast cancer in the elderly US population. METHODS: The primary outcome was receipt of BCT. The 2003 to 2004 Medicare inpatient, outpatient, and carrier files were used to identify incident breast cancer patients and the American Medical Association to ascertain surgeon information. The primary independent variables were US state where treatment was performed along with patient and surgeon sociodemographic information. Multivariate logistic regression was used for the analyses. RESULTS: BCT was performed in 81.8% of patients (N = 20,032). Variation in use of BCT across states was low, ranging from 74.2% in Utah to 84.0% in New Mexico. Several factors were significantly associated with low use of BCT: advanced patient age (>85 vs 3 vs ≤3: OR, 0.26; 95% CI, 0.24-0.28), and low socioeconomic status (SES) (lowest quintile vs highest quintile SES: OR, 0.60; 95% CI, 0.52-0.68). Variation in use of BCT by surgeon was low, although female surgeons aged 40 to 49 years and ≥60 years had significantly higher use compared with younger men. CONCLUSIONS: BCT has become the primary management among elderly breast cancer patients. Despite earlier studies to the contrary, there is now little variation in BCT use among Medicare patients. Cancer 2011. © 2010 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/83176/1/25617_ftp.pd

Hospitalist Staffing and Patient Satisfaction in the National Medicare Population

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96722/1/jhm2001.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/96722/2/jhm2001-sup-0001-suppinfo.pd

Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/1/hesr12482_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/2/hesr12482.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135970/3/hesr12482-sup-0001-AuthorMatrix.pd

Medicare Payments for Common Inpatient Procedures: Implications for Episode-Based Payment Bundling

Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.Using the national Medicare database, we identified patients undergoing one of four inpatient procedures in 2005 (coronary artery bypass [CABG], hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days postdischarge were assessed and categorized by payment type (hospital, physician, and postacute care) and subtype.Average total payments for inpatient surgery episodes varied from U.S.$26,515 for back surgery to U.S.$45,358 for CABG. Hospital payments accounted for the largest share of total payments (60–80 percent, depending on procedure), followed by physician payments (13–19 percent) and postacute care (7–27 percent). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by U.S.$16,668 for CABG, U.S.$18,762 for back surgery, U.S.$10,615 for hip fracture repair, and U.S.$12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions and postacute care varied most substantially across hospitals.Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments—both overall and for specific services—vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79298/1/j.1475-6773.2010.01150.x.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/79298/2/HESR_1150_sm_authormatrix.pd

Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97509/1/jhm2013.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/97509/2/jhm2013-sup-0001-suppinfo.pd

Measuring Surgical Quality: What’s the Role of Provider Volume?

Although not ideal for all situations, provider volume is particularly suited for measuring surgical quality in certain contexts. Specifically, we believe that for uncommon operations with a strong volumes–outcome effect, provider volume may be the most informative performance measure. Because of the relative ease of determining provider volume, it will continue to be used in value-based purchasing and public reporting efforts. With increasing momentum from outside the profession of surgery, it is particularly important for surgeons to participate in making decisions regarding situations where volume may be an appropriate measure of quality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41304/1/268_2005_Article_7989.pd

Treatment of Gastric Adenocarcinoma May Differ Among Hospital Types in the United States, a Report from the National Cancer Data Base

The concept that complex surgical procedures should be performed at high-volume centers to improve surgical morbidity and mortality is becoming widely accepted. We wanted to determine if there were differences in the treatment of patients with gastric cancer between community cancer centers and teaching hospitals in the United States. Data from the 2001 Gastric Cancer Patient Care Evaluation Study of the National Cancer Data Base comprising 6,047 patients with gastric adenocarcinoma treated at 691 hospitals were assessed. The mean number of patients treated was larger at teaching hospitals (14/year) when compared to community centers (5–9/year) (p < 0.05). The utilization of laparoscopy and endoscopic ultrasonography were significantly more common at teaching centers (p < 0.01). Pathologic assessment of greater than 15 nodes was documented in 31% of specimen at community hospitals and 38% at teaching hospitals (p < 0.01). Adjusted for cancer stage, chemotherapy and radiation therapy were utilized with equal frequency at all types of treatment centers. The 30-day postoperative mortality was lowest at teaching hospitals (5.5%) and highest at community hospitals (9.9%) (p < 0.01). These data support previous publications demonstrating that patients with diseases requiring specialized treatment have lower operative mortality when treated at high-volume centers

Volume and outcomes relationship in laparoscopic diaphragmatic hernia repair

BackgroundThere is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that hospitals performing high case volume have improved outcomes compared to low-volume hospitals.Materials and methodsWe reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 for adults with the diagnosis of diaphragmatic hernia who underwent elective laparoscopic repair of diaphragmatic Hernia and/or Nissen fundoplication. Pediatric, emergent, and open cases were excluded. Main outcome measures included logistic regression analysis of factors predictive of in-hospital mortality and outcomes according to annual hospital case volume.ResultsA total of 31,228 laparoscopic diaphragmatic hernia operations were analyzed. The overall in-hospital mortality was 0.14%. Risk factors for higher in-hospital mortality included renal failure (AOR: 6.26; 95% CI: 2.48-15.78; p &lt; 0.001), age&gt;60 years (AOR: 5.06; 95% CI: 2.38-10.76; p &lt; 0.001), and CHF (AOR: 3.80; 95% CI: 1.39-10.38; p = 0.009) while an incremental increase in volume of 10 cases/year (AOR: 0.89; 95% CI: 0.81-0.98; p = 0.019) and diabetes (AOR: 0.34; 95% CI: 0.12-0.93; p = 0.036) decreases mortality. There was a small but significant inverse relationship between hospital case volume and mortality with a 10% reduction in adjusted odds of in-hospital mortality for every increase in 10 cases per year. Using 10 cases per year as the volume threshold, low-volume hospitals (≤10 cases/year) had almost a twofold higher mortality compared to high-volume hospitals (0.23 vs. 0.12%, respectively, p = 0.02).ConclusionsThere was a small but significant inverse relationship between the hospitals' case volume and mortality in laparoscopic diaphragmatic hernia repair