Novel Uses of Video to Accelerate the Surgical Learning Curve

Surgeons are under enormous pressure to continually improve and learn new surgical skills. Novel uses of surgical video in the preoperative, intraoperative, and postoperative setting are emerging to accelerate the learning curve of surgical skill and minimize harm to patients. In the preoperative setting, social media outlets provide a valuable platform for surgeons to collaborate and plan for difficult operative cases. Live streaming of video has allowed for intraoperative telementoring. Finally, postoperative use of video has provided structure for peer coaching to evaluate and improve surgical skill. Applying these approaches into practice is becoming easier as most of our surgical platforms (e.g., laparoscopic, and endoscopy) now have video recording technology built in and video editing software has become more user friendly. Future applications of video technology are being developed, including possible integration into accreditation and board certification.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140152/1/lap.2016.0100.pd

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

Hospital quality, patient risk, and Medicare expenditures for cancer surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142437/1/cncr31120.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142437/2/cncr31120_am.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

A True Aneurysm of the Profunda Femoris Artery: A Case Report and Review of the English Language Literature

A rare case of true aneurysm of the profunda femoris artery (PFA) is reported. Surgical management consisted of ligation of the aneurysm and decompression of the sac. Presentation, diagnosis, and treatment of true PFA aneurysms are discussed and the English language literature is comprehensively reviewed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41367/1/10016_2004_Article_116.pd

Evaluation of US Hospital Episode Spending for Acute Inpatient Conditions After the Patient Protection and Affordable Care Act.

Importance: Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts. Objective: To evaluate the association between the enactment of ACA reforms and 30-day price-standardized hospital episode spending. Design, Setting, and Participants: This policy evaluation included index discharges between January 1, 2008, and August 31, 2015, from a national random 20% sample of Medicare beneficiaries. Data analysis was performed from February 1, 2019 to July 8, 2020. Exposure: Payment reforms after passage of the ACA. Main Outcomes and Measures: 30-day price-standardized episode payments. Three alternative estimation approaches were used to evaluate the association between reforms following the ACA and episode spending: (1) a difference-in-difference (DID) analysis among acute care hospitals, comparing spending for diagnoses commonly targeted by ACA programs with nontargeted diagnoses; (2) a DID analysis comparing acute care hospitals and critical access hospitals (not exposed to reforms); and (3) a generalized synthetic control analysis, comparing acute care and critical access hospitals. Supplemental analysis examined the degree to which Medicare fee cuts contributed to spending reductions. Results: A total of 7 634 242 index discharges (4 525 630 [59.2%] female patients; mean [SD] age, 79.31 [8.02] years) were included. All 3 approaches found that reforms following the ACA were associated with a significant reduction in episode spending. The DID estimate comparing targeted and untargeted diagnoses suggested that reforms following the ACA were associated with a -$431 (95$492 to -$369; -2.87$1232 (95% CI, -$1488 to -$965; -10.12%) change in total episode spending, amounting in a total annual savings of $5.68 billion. Cuts to Medicare fees accounted for most of these savings. Conclusions and Relevance: In this policy evaluation, the ACA was associated with large reductions in US hospital episode spending

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

Trends in Utilization of Adrenalectomy in the United States: Have Indications Changed?

Minimally invasive approaches have dramatically reduced morbidity associated with adrenalectomy. There has been concern that an increased frequency of adrenal imaging along with the advantages of less morbidity could influence the indications for adrenalectomy. We tested the hypothesis that adrenalectomy has become more common over time and that benign diseases have been increasingly represented among procedural indications. The Nationwide Inpatient Sample (NIS) database was utilized to determine the incidence of adrenalectomy and the associated surgical indications in the United States between 1988 and 2000. All discharged patients were identified whose primary ICD-9-CM procedure code was for adrenalectomy, regardless of the specific surgical approach (laparoscopic adrenalectomy was not reliably coded). This subset was then queried for associated ICD-9-CM diagnostic codes. Linear regression and t -tests were utilized to determine the significance of trends. The total number of adrenalectomies increased significantly, from 12.9 per 100,000 discharges in 1988 to 18.5 per 100,000 discharges in 2000 ( p = 0.000003). The total number of adrenalectomies with a primary ICD-9-CM code for malignant adrenal neoplasm did not increase significantly: from 1.2 per 100,000 discharges in 1988 to 1.6 per 100,000 discharges in 2000 ( p = 0.47). The total number of adrenalectomies with a primary ICD-9-CM diagnostic code for benign adrenal neoplasm increased significantly, from 2.8 per 100,000 discharges in 1988 to 4.8 per 100,000 discharges in 2000 ( p = 0.00002). The average percentage of adrenalectomies performed for malignant neoplasm was significantly higher during the period 1988–1993 when compared to 1994–2000 (11% vs. 9%; p = 0.002). The average percentage of adrenalectomies performed for benign neoplasm was significantly lower during 1988–1993 when compared to 1994–2000 (25% vs. 28%; p = 0.015). Adrenalectomy is being performed with increasing frequency. This is associated with an increase in the proportion of adrenalectomies performed for benign neoplasms. Assuming no significant change in disease prevalence during the study period, these data suggest that indications for adrenalectomy may have changed somewhat over that period.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41300/1/268_2004_Article_7619.pd

A Video is Worth a Thousand Operative Notes

At the conclusion of this presentation the participant should be able to: To appreciate the trade-offs with the two fundamental mechanisms for improving patient outcomes—selective referral and quality improvement. To understand the gaps in our current approaches for improving patient outcomes in surgery. To learn how video analysis and peer coaching could be used to fill existing gaps in surgical performance improvement