Identification of in-hospital complications from claims data. Is it valid?

Rising post-colectomy complications in children with ulcerative colitis despite stable colectomy rates in United States

BACKGROUND AND AIMS

In children with ulcerative colitis, data on temporal colectomy trends and in-hospital post-colectomy complications are limited. Thus, we evaluated time trends in colectomy rates and post-colectomy complications in children with ulcerative colitis.

METHODS

We identified all children (≤18years) with a diagnosis code of ulcerative colitis (ICD-9: 556.X) and a procedure code of colectomy (ICD-9: 45.8 and 45.7) in the Kids' Inpatient Database for 1997, 2000, 2003, 2006 and 2009. The incidence of colectomies for pediatric ulcerative colitis was calculated and Poisson regression analysis was performed to evaluate the change in colectomy rates. In-hospital postoperative complication rates were assessed and predictors for postoperative complications were evaluated using multivariate logistic regression.

RESULTS

The annual colectomy rate in pediatric ulcerative colitis was 0.43 per 100,000person-years, which was stable throughout the study period (P>.05). Postoperative complications were experienced in 25%, with gastrointestinal (13%) and infectious (9.3%) being the most common. Postoperative complication rates increased significantly by an annual rate of 1.1% from 1997 to 2009 (P=.01). However, other independent predictors of postoperative complications were not identified. Patients with postoperative complications had significantly longer median length of stay (14.3days vs 8.2days; P<.001) and higher median hospital charges per patient (US $81,567 vs US $55,461; P<.001) compared to those without complications.

CONCLUSION

Colectomy rates across the United States in children with ulcerative colitis have remained stable between 1997 and 2009; however, in-hospital postoperative complication rates have increased.

Failure-to-rescue and interprovider comparisons after elective abdominal aortic aneurysm repair

BACKGROUND

The use of postoperative complication rates to derive metrics such as failure-to-rescue (FTR) is of increasing interest in assessing the quality of care. The aim of this study was to quantify FTR rates for elective abdominal aortic aneurysm (AAA) repair in England using administrative data, and to examine its validity against case-note review.

METHODS

A retrospective observational study using Hospital Episode Statistics (HES) data was combined with a multicentre audit of data quality. All elective AAA repairs done in England between 2005 and 2010 were identified. Postoperative complications were extracted, FTR rates quantified, and differences in FTR and in-hospital death rates established. A multicentre case-note review was performed to establish the accuracy of coding of complications, and the impact of inaccuracies on FTR rates derived from HES data.

RESULTS

A total of 19 638 elective AAA repairs were identified from HES; the overall mortality rate was 4·6 per cent. Patients with complications (19·2 per cent) were more likely to die than those without complications (odds ratio 12·22, 95 per cent c.i. 10·51 to 14·21; P < 0·001) and had longer hospital stays (P < 0·001). FTR rates correlated strongly with death rates, whereas complication rates did not. On case-note review (661 procedures), 41·5 per cent of patients had a complication recorded in the case notes. There was evidence of systematic under-reporting of complications in HES, leading to an overall misclassification rate of 36·3 (95 per cent c.i. 33·7 to 39·2) per cent (P < 0·001), which was less pronounced for surgical complications (12·6 (11·1 to 13·9) per cent; P <0·001). Despite this, the majority of FTR rates derived from HES were not significantly different from those derived from case-note data.

CONCLUSION

Postoperative complication and FTR rates after elective AAA repair can be derived from HES data. However, use of the metric for interprovider comparisons should be done cautiously, and only with concurrent case-note validation given the degree of miscoding identified.

Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care patients on mechanical ventilation

RATIONALE, AIMS AND OBJECTIVES

Pressure ulcers (PUs) are a common and serious complication in critically ill patients. The aim of this study was to evaluate the relationship between the development of a PU and hospital mortality in patients requiring mechanical ventilation (MV) in an intensive care unit (ICU).

METHODS

A prospective cohort study was performed over two years in patients requiring MV for ≥ 24 hours in a medical-surgical ICU. Primary outcome measure was hospital mortality and main independent variable was the development of a PU grade ≥ II. Hazard ratios (HRs) were calculated using a Cox model with time-dependent covariates.

RESULTS

Out of 563 patients in the study, 110 (19.5%) developed a PU. Overall hospital mortality was 48.7%. In the adjusted multivariate model, PU onset was a significant independent predictor of mortality (adjusted HR, 1.28; 95% confidence interval, 1.003-1.65; P = 0.047). The model also included the Acute Physiology and Chronic Health Evaluation II score, total Sequential Organ Failure Assessment on day 3, hepatic cirrhosis and medical admission.

CONCLUSION

Within the limitations of a single-centre approach, PU development appears to be associated with an increase in mortality among patients requiring MV for 24 hours or longer.

Comparative inpatient resource utilization for patients undergoing endoscopic or microscopic transsphenoidal surgery for pituitary lesions

Object

An increasingly important measure in the health care field is utilization of hospital resources, particularly in the context of emerging surgical techniques. Despite the recent widespread adoption of the endoscopic transsphenoidal approach for pituitary lesion surgery, the health care resources utilized with this approach have not been compared with those utilized with the traditional microscopic approach. The purpose of this study was to determine the drivers of resource utilization by comparing hospital charges for patients with pituitary tumors who had undergone either endoscopic or microscopic transsphenoidal surgery.

Methods

A complete accounting of all hospital charges for 166 patients prospectively enrolled in a surgical quality-of-life study at a single pituitary center during October 2011–June 2013 was undertaken. Patients were assigned to surgical technique group according to surgeon preference and then managed according to a standard postoperative institutional set of orders. Individual line-item charges were assigned to categories (such as pharmacy, imaging, surgical, laboratory, room, pathology, and recovery unit), and univariate and multivariate statistical analyses were conducted.

Results

Of the 166 patients, 99 underwent microscopic surgery and 67 underwent endoscopic surgery. Baseline demographic descriptors and tumor characteristics did not differ significantly. Mean total hospital charges were $74,703 ± $15,142 and $72,311 ± $16,576 for microscopic and endoscopic surgery patients, respectively (p = 0.33). Furthermore, other than for pathology, charge categories did not differ significantly between groups. A 2-step multivariate regression model revealed that length of stay was the most influential variable, followed by a diagnosis of Cushing's disease, and then by endoscopic surgical technique. The model accounts for 42% of the variance in hospital charges.

Conclusions

Study findings suggest that adoption of the endoscopic transsphenoidal technique for pituitary lesions does not adversely affect utilization of resources for inpatients. The primary drivers of hospital charges, in order of importance, were length of stay, a diagnosis of Cushing's disease, and, to a lesser extent, use of the endoscopic technique. This study also highlights the influence of individual surgeon practice patterns on resource utilization.

Physician social networks and variation in rates of complications after radical prostatectomy

OBJECTIVES

Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy.

METHODS

In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume.

RESULTS

Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications.

CONCLUSIONS

Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems

BACKGROUND CONTEXT

In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion.

PURPOSE

The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies.

STUDY DESIGN AND SETTING

The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009.

PATIENT SAMPLE

All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample.

OUTCOME MEASURE(S)

Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs.

METHODS

Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics.

RESULTS

Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114).

CONCLUSIONS

Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.

Rankings versus reality in pancreatic cancer surgery: a real-world comparison

BACKGROUND

Patients are increasingly confronted with systems for rating hospitals. However, the correlations between publicized ratings and actual outcomes after pancreatectomy are unknown.

METHODS

The Massachusetts Division of Health Care Finance and Policy Hospital Inpatient Discharge Database was queried to identify pancreatic cancer resections carried out during 2005-2009. Hospitals performing fewer than 10 pancreatic resections in the 5-year period were excluded. Primary outcomes included mortality, complications, median length of stay (LoS) and a composite outcomes score (COS) combining primary outcomes. Ranks were determined and compared for: (i) volume, and (ii) ratings identified from consumer-directed hospital ratings including the US News & World Report (USN), Consumer Reports, Healthgrades and Hospital Compare. An inter-rater reliability analysis was performed and correlation coefficients (r) between outcomes and ratings, and between rating systems were calculated.

RESULTS

Eleven hospitals in which a total of 804 pancreatectomies were conducted were identified. Surgical volume correlated with overall outcome, but was not the strongest indicator. The highest correlation referred to that between USN rank and overall outcome. Mortality was most strongly correlated with Healthgrades ratings (r = 0.50); however, Healthgrades ratings demonstrated poorer correlations with all other outcomes. Consumer Reports ratings showed inverse correlations.

CONCLUSIONS

The plethora of publicly available hospital ratings systems demonstrates heterogeneity. Volume remains a good but imperfect indicator of surgical outcomes. Further systematic investigation into which measures predict quality outcomes in pancreatic cancer surgery will benefit both patients and providers.

Variation in outcomes of quality measurement by data source

OBJECTIVE

To evaluate selected Children's Health Insurance Program Reauthorization Act claims-based quality measures using claims data alone, electronic health record (EHR) data alone, and both data sources combined.

METHODS

Our population included pediatric patients from 46 clinics in the OCHIN network of community health centers, who were continuously enrolled in Oregon's public health insurance program during 2010. Within this population, we calculated selected pediatric care quality measures according to the Children's Health Insurance Program Reauthorization Act technical specifications within administrative claims. We then calculated these measures in the same cohort, by using EHR data, by using the technical specifications plus clinical data previously shown to enhance capture of a given measure. We used the k statistic to determine agreement in measurement when using claims versus EHR data. Finally, we measured quality of care delivered to the study population, when using a combined dataset of linked, patient-level administrative claims and EHR data.

RESULTS

When using administrative claims data, 1.0% of children (aged 3-17) had a BMI percentile recorded, compared with 71.9% based on the EHR data (k agreement [k] # 0.01), and 72.0% in the combined dataset. Among children turning 2 in 2010, 20.2% received all recommended immunizations according to the administrative claims data, 17.2% according to the EHR data (k = 0.82), and 21.4% according to the combined dataset.

CONCLUSIONS

Children's care quality measures may not be accurate when assessed using only administrative claims. Adding EHR data to administrative claims data may yield more complete measurement.

Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To examine the complications, reoperation rates, and resource use after each of the surgical approaches for the treatment of spinal stenosis.

SUMMARY OF BACKGROUND DATA

There are no uniform guidelines for which procedure (decompression, decompression with instrumentation, or decompression with noninstrumented fusion) to perform for the treatment of spinal stenosis. With no clear evidence for increased efficacy, the rate of instrumented fusions is rising.

METHODS

We performed a retrospective cohort analysis of patients who underwent spinal stenosis surgery between 2002 and 2009 in the United States. Patients included (n = 12,657) were diagnosed with spinal stenosis without concurrent spondylolisthesis and had at least 2 years of preoperative enrollment. A total of 2385 patients with decompression only and 620 patients with fusion had follow-up data for 5 years or more.

RESULTS

Complication rates during the initial procedure hospitalization and at 90 days were significantly higher for those who underwent laminectomy with fusion than for those who underwent laminectomy alone, with reoperation rates not differing significantly between these groups. Long-term (≥5 yr) reoperation rates were similar for those undergoing decompression alone versus decompression with fusion (17.3% vs. 16.0%, P = 0.44). Those with instrumented fusions had a slightly higher rate of reoperation than patients with noninstrumented fusions (17.4% vs. 12.2%, P = 0.11) at more than 5 years. The total cost including initial procedure and hospital, outpatient, emergency department, and medication charges at 5 years was similar for those who received decompression alone and fusion. The long-term costs for instrumented and noninstrumented fusions were also similar, totaling $107,056 and $100,471, respectively.

CONCLUSION

For patients with spinal stenosis, if fusion is warranted, use of arthrodesis without instrumentation is associated with decreased costs with similar long-term complication and reoperation rates.

Is robot-assisted radical prostatectomy safe in men with high-risk prostate cancer? Assessment of perioperative outcomes, positive surgical margins, and use of additional cancer treatments

INTRODUCTION

Despite a rapid dissemination of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP), to date no study has compared perioperative outcomes between the two approaches in patients with high-risk prostate cancer (PCa). The aim of our study was to evaluate the safety and feasibility of RARP in this setting.

PATIENTS AND METHODS

Overall, 1,512 patients with high-risk PCa within the Surveillance, Epidemiology, and End RESULTS (SEER) Medicare-linked database diagnosed between 2008 and 2009 were abstracted. Patients were treated with RARP or ORP. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), positive surgical margins, and additional cancer therapy rates were compared. Propensity-score matched analyses and logistic regression models fitted with generalized estimating equations for clustering among hospitals were performed.

RESULTS

Overall, 706 (46.7%) and 806 (53.3%) patients underwent ORP and RARP, respectively. Following propensity-matched analyses, 706 patients remained. No differences were observed in complications (P=0.6), positive surgical margins (P=0.4), or additional therapy after surgery (P=0.2) between patients treated with RARP and ORP; however, RARP was associated with lower rates of transfusions and shorter hospitalization (all P<0.001). In multivariable analyses, patients undergoing RARP were less likely to receive a blood transfusion (P=0.002) or to experience pLOS (P<0.001) compared with men treated with ORP.

CONCLUSIONS

RARP and ORP have comparable complications, positive surgical margins, and additional cancer therapy rates in high-risk PCa. RARP is associated with lower rates of blood transfusions and shorter hospital stays. These findings suggest that RARP is safe and feasible even in this clinical scenario.

National trends in pancreaticoduodenal trauma: interventions and outcomes

OBJECTIVES

Pancreaticoduodenal trauma (PDT) is associated with substantial mortality and morbidity. In this study, contemporary trends were analysed using national data.

METHODS

The Nationwide Inpatient Sample for 1998-2009 was queried for patients with PDT. Interventions including any operation (Any-Op) and pancreas-specific surgery (PSURG) were identified. Trends in treatment and outcomes were determined [complications, length of stay (LoS), mortality] for the Any-Op, PSURG and non-operative (Non-Op) groups. Analyses included chi-squared tests, Cochran-Armitage trend tests and logistic regression.

RESULTS

A total of 27 216 patients (nationally weighted) with PDT were identified. Over time, the frequency of PDT increased by 8.3%, whereas the proportion of patients submitted to PSURG declined (from 21.7% to 19.8%; P = 0.0004) and the percentage of patients submitted to non-operative management increased (from 56.7% to 59.1%; P = 0.01). In the Non-Op group, mortality decreased from 9.7% to 8.6% (P < 0.001); morbidity and LoS remained unchanged at ∼40% and ∼12 days, respectively. In the PSURG group, mortality remained stable at ∼15%, complications increased from 50.2% to 71.8% (P < 0.0001) and LoS remained stable at ∼21 days. For all PDT patients, significant independent predictors of mortality included: the presence of combined pancreatic and duodenal injuries; penetrating trauma, and age >50 years. Having any operation (Any-Op) was associated with mortality, but PSURG was not a predictor of death.

CONCLUSIONS

The utilization of operations for PDT has declined without affecting mortality, but operative morbidity increased significantly over the 12 years to 2009. The development of an evidence-based approach to invasive manoeuvres and an early multidisciplinary approach involving pancreatic surgeons may improve outcomes in patients with these morbid injuries.

The effect of neoadjuvant chemotherapy on perioperative outcomes in patients who have bladder cancer treated with radical cystectomy: a population-based study

BACKGROUND

Although therapeutic guidelines recommend the use of neoadjuvant chemotherapy before radical cystectomy (RC) in patients who have muscle-invasive bladder cancer (MIBC), this approach remains largely underused. One of the main reasons for this phenomenon might reside in concerns regarding the risk of morbidity and mortality associated with neoadjuvant chemotherapy.

OBJECTIVE

To compare perioperative outcomes between patients receiving neoadjuvant chemotherapy and those treated with RC alone.

DESIGN, SETTING, AND PARTICIPANTS

Relying on the Surveillance Epidemiology and End Results-Medicare-linked database, 3760 patients diagnosed with MIBC between 2000 and 2009 were evaluated.

INTERVENTION

RC alone or RC plus neoadjuvant chemotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Complications occurred within 30 and 90 d after surgery. Heterologous blood transfusions (HBTs), length of stay (LoS), readmission, and perioperative mortality were compared. To decrease the effect of unmeasured confounders associated with treatment selection, propensity score-matched analyses were performed.

RESULTS AND LIMITATIONS

Overall, 416 (11.1%) of patients received neoadjuvant chemotherapy. Following propensity score matching, 416 (20%) and 1664 (80%) patients treated with RC plus neoadjuvant chemotherapy and RC alone remained, respectively. The 30-d complication, readmission, and mortality rates were 66.0%, 32.2%, and 5.3%, respectively. The 90-d complication, readmission, and mortality rates were 72.5%, 46.6%, and 8.2%, respectively. When patients were stratified according to neoadjuvant chemotherapy status, no significant differences were observed in the rates of complications, HBT, prolonged LoS, readmission, and mortality between the two groups (all p ≥ 0.1). These results were confirmed in multivariate analyses, where the use of neoadjuvant chemotherapy was not associated with higher risk of 30- and 90-d complications, HBT, prolonged LoS, readmission, and mortality (all p ≥ 0.1). Our study is limited by its retrospective nature.

CONCLUSIONS

The use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality. These results should encourage wider use of neoadjuvant chemotherapy when clinically indicated.

PATIENT SUMMARY

Chemotherapy before radical cystectomy in patients with muscle-invasive bladder cancer does not increase the risk of complications or death. The use of chemotherapy should be strongly encouraged, as recommended by clinical guidelines, given its benefits.

Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research.

METHODS AND RESULTS

This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care.

CONCLUSIONS

There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.

In-hospital death and hospital-acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States

BACKGROUND

Partial cystectomy (PC) is a therapeutic option for select patients with bladder cancer, but its associated perioperative risks and costs are unknown. We estimated annual rates of PC in a nationally representative sample of hospitals, and analyzed whether hospital volume affects postoperative outcomes and costs in patients undergoing PC.

METHODS

From the Nationwide Inpatient Sample, we selected a weighted cohort of patients with bladder cancer who underwent PC between 2002 and 2008. Differences in length of stay, charges, and clinical outcomes were calculated based on operative volume, and univariate and multivariate regression models were fitted to predict in-hospital mortality (IHM) and hospital-acquired conditions.

RESULTS

A total of 10,780 patients with bladder cancer who underwent PC were identified with an annual rate between 1457 and 1628 cases. IHM rates were 1.8%, constituting 195 patients (between 9 and 46 annually). A total of 417 patients (3.9%) experienced a "never event" complication, which Medicare no longer reimburses. The mean annual hospital volume of patients who died was 1.7 cases/y compared with 2.4 cases/y among those without fatal complications. No cases of IHM were identified among hospitals performing at least 5 partial cystectomies/y. In a multivariate regression model increased hospital volume was independently associated with decreased mortality (odds ratio = 0.70, 95% confidence interval; 0.60-0.80).

CONCLUSIONS

Approximately 1 in 25 patients undergoing PC experience a hospital-acquired complication, and nearly 1 in 50 die as a result of the operation. For each additional case a hospital performs annually, the risk of IHM decreases by 30%.

Serious postoperative infections following resection of common solid tumors: outcomes, costs, and impact of hospital surgical volume

PURPOSE

Unlike infections related to chemotherapy-induced neutropenia, postoperative infections occurring in patients with solid malignancy remain largely understudied. Our aim is to evaluate the outcomes and the volume-outcomes relationship associated with postoperative infections following resection of common solid tumors.

METHODS

We used Texas Discharge Data to study patients undergoing resection of cancer of the lung, esophagus, stomach, pancreas, colon, or rectum from 01/2002 to 11/2006. From their billing records, we identified ICD-9 codes indicating a diagnosis of serious postoperative infection (SPI), i.e., bacteremia/sepsis, pneumonia, and wound infection, occurring during surgical admission or leading to readmission within 30 days of surgery. Using regression-based techniques, we estimated the impact of SPI on mortality, resource utilization, and costs, as well as the relationship between hospital volume and SPI, after adjusting for confounders and data clustering.

RESULTS

SPI occurred following 9.4 % of the 37,582 eligible tumor resections and was independently associated with nearly 12-fold increased odds of in-hospital mortality [95 % confidence interval (95 % CI), 7.2-19.5, P < 0.001]. Patients with SPI required six additional hospital days (95 % CI, 5.9-6.2) at an incremental cost of $16,991 (95 % CI, $16,495-$17,497). Patients who underwent resection at high-volume hospitals had a 16 % decreased odds of developing SPI than those at low-volume hospitals (P = 0.03).

CONCLUSIONS

Due to the substantial burden associated with SPI following common solid tumor resections, hospitals must identify more effective prophylactic measures to avert these potentially preventable infections. Additional volume-outcomes research is needed to identify infection prevention processes that can be transferred from high- to lower-volume providers.

Evaluation of paediatric nursing-sensitive outcomes in an Australian population using linked administrative hospital data

BACKGROUND

Research into nursing-sensitive outcomes using administrative health data has focussed on hospitalised adults. However, we developed algorithms for the identification of 13 paediatric nursing-sensitive outcomes, which we seek to examine for clinical utility. The aims were to determine the rates of paediatric nursing-sensitive outcomes in a Western Australian hospital and ascertain sociodemographic and clinical characteristics associated with a greater risk of developing nursing-sensitive outcomes in hospitalised children.

METHOD

A retrospective cohort study used linked administrative data of all Western Australian children ≤18 years admitted to the only tertiary paediatric hospital in Perth between 1999 and 2009. Rates per 1,000 hospital separations and per 10,000 patient days were calculated for the following nursing-sensitive outcomes: lower respiratory tract infection (LRTI), gastrointestinal (GI) infection, pneumonia, sepsis, arrest/shock/respiratory failure, central nervous system complication, central venous line infection, infectious disease, pressure ulcer, failure to rescue, surgical wound infection, physiologic/metabolic derangement, and postoperative cardiopulmonary complications. Poisson multiple regression models were fitted to estimate rate ratios (RR) and 95% confidence intervals (CI) for suspected risk factors.

RESULTS

Linked records of 129,719 hospital separations were analysed. Rates ranged from 0.5/1,000 for pressure ulcer to 14.0/1,000 hospital separations for GI infections. Age was significantly associated with the risk of a nursing-sensitive outcome: compared with adolescents, toddlers had greater risk of GI infection (RR 9.89; 95% CI 6.24, 15.69); infants had 7.74 times greater risk of LRTI (95% CI 5.11, 11.75), while neonates had lower risks for sepsis (RR 0.26; 95% CI 0.08, 0.90) and physiologic/metabolic derangement (RR 0.12; 95% CI 0.04, 0.35). The risk of surgical wound infection was 7.78 times greater (95% CI 5.10, 11.86) for emergency admissions than elective admissions.

CONCLUSIONS

Seven of the 13 defined nursing-sensitive outcomes occurred with sufficient frequency (>100 events over the 10 year study period) to be potentially useful for monitoring the quality of nursing care. These nursing-sensitive outcomes are: LRTI, GI infection, pneumonia, surgical wound infection, physiologic/metabolic derangement, sepsis and postoperative cardiopulmonary complications. When used for quality improvement or to benchmark with other agencies, data need to be adjusted for, or stratified by age and admission type, to ensure equitable comparisons.

Detecting postoperative hemorrhage or hematoma from administrative data: the performance of the AHRQ Patient Safety Indicator

BACKGROUND

Patient Safety Indicator (PSI) 9, "postoperative hemorrhage or hematoma" (PHH), of the US Agency for Healthcare Research and Quality has been considered for public quality of care reporting. We sought to evaluate its performance in detecting true complications.

METHODS

We conducted a retrospective, cross-sectional study of hospitalizations that met PSI 9 eligibility criteria. We sampled records flagged positive and negative by PSI 9 from a diverse set of 31 hospitals between February 2006, and June 2009. Trained abstractors reviewed medical records using standard instruments. We determined the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of the indicator.

RESULTS

Of 181 analyzable records flagged by PSI 9, 168 (93%; weighted PPV, 95% [95% confidence interval (CI), 90-98%]) involved an accurately coded event, but only 126 (70%; weighted PPV, 78% [95% CI, 58-90%]) represented true PHH. Thirty-two false positives involved only intraoperative hemorrhage. Among true positives, hypotension occurred in 28% and death attributed to the PHH in 4%. Thirty-two of 281 records flagged negative by PSI 9 (but enriched with questionably negative records) represented true PHH. The indicator's sensitivity was 42% (95% CI, 23-64%), specificity 99.9% (95% CI, 99.8-100%), and NPV 99.7% (95% CI, 99.0-99.9%). Modifying the indicator to include additional procedure codes improved both sensitivity (85% [95% CI, 67-94%]) and PPV (76% [95% CI, 60-88%]).

CONCLUSION

PSI 9 holds promise in detecting serious, possibly preventable complications. The indicator might be improved by specification of the 998.11 hemorrhage code to exclude purely intraoperative events and addition of procedure codes to the indicator's numerator criteria.

Major medical outcomes with spinal augmentation vs conservative therapy

IMPORTANCE

The symptomatic benefits of spinal augmentation (vertebroplasty or kyphoplasty) for the treatment of osteoporotic vertebral compression fractures are controversial. Recent population-based studies using medical billing claims have reported significant reductions in mortality with spinal augmentation compared with conservative therapy, but in nonrandomized settings such as these, there is the potential for selection bias to influence results.

OBJECTIVE

To compare major medical outcomes following treatment of osteoporotic vertebral fractures with spinal augmentation or conservative therapy. Additionally, we evaluate the role of selection bias using preprocedure outcomes and propensity score analysis.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis of Medicare claims for the 2002-2006 period. We compared 30-day and 1-year outcomes in patients with newly diagnosed vertebral fractures treated with spinal augmentation (n = 10,541) or conservative therapy (control group, n = 115,851). Outcomes were compared using traditional multivariate analyses adjusted for patient demographics and comorbid conditions. We also used propensity score matching to select 9017 pairs from the initial groups to compare the same outcomes.

EXPOSURES

Spinal augmentation (vertebroplasty or kyphoplasty) or conservative therapy.

MAIN OUTCOMES AND MEASURES

Mortality, major complications, and health care utilization.

RESULTS

Using traditional covariate adjustments, mortality was significantly lower in the augmented group than among controls (5.2% vs 6.7% at 1 year; hazard ratio, 0.83; 95% CI, 0.75-0.92). However, patients in the augmented group who had not yet undergone augmentation (preprocedure subgroup) had lower rates of medical complications 30 days post fracture than did controls (6.5% vs 9.5%; odds ratio, 0.66; 95% CI, 0.57-0.78), suggesting that the augmented group was less medically ill. After propensity score matching to better account for selection bias, 1-year mortality was not significantly different between the groups. Furthermore, 1-year major medical complications were also similar between the groups, and the augmented group had higher rates of health care utilization, including hospital and intensive care unit admissions and discharges to skilled nursing facilities.

CONCLUSIONS AND RELEVANCE

After accounting for selection bias, spinal augmentation did not improve mortality or major medical outcomes and was associated with greater health care utilization than conservative therapy. Our results also highlight how analyses of claims-based data that do not adequately account for unrecognized confounding can arrive at misleading conclusions.

Incidence, risk factors, and mortality associated with aspiration in cervical spine surgery

STUDY DESIGN

Retrospective national database analysis.

OBJECTIVE

A population-based database was analyzed to characterize the incidence, mortality, and associated risk factors for aspiration pneumonia in cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Aspiration pneumonia represents a potentially fatal complication of any surgical procedure. The incidence of this complication is not well characterized after cervical spine surgery.

METHODS

Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing anterior cervical fusion, posterior cervical fusion, or posterior cervical decompression for radiculopathy and/or myelopathy were identified. Patient demographics, incidence of aspiration, costs, and mortalities were assessed. Statistical analysis was performed using Student t test for discrete variables and χ test for categorical data. Logistic regression was used to identify independent predictors for aspiration.

RESULTS

A total of 202,694 patients were identified in the Nationwide Inpatient Sample from 2002 to 2009. Of these, 166,633 were anterior cervical fusions (82.2%), 13,298 were posterior cervical fusions (6.6%), and 22,764 were posterior cervical decompressions (11.2%). The overall incidence of aspiration was 5.3 events per 1000 cases. The greatest incidence was demonstrated in posterior cervical fusion-treated patients with 13.7 per 1000 cases, followed by posterior cervical decompressions with 6.4 per 1000 and anterior cervical fusions with 4.5 per 1000. Patients affected by aspiration were significantly older, more frequently male, and had greater comorbidities than unaffected patients (P < 0.001). Patients diagnosed with aspiration demonstrated significantly greater length of stay, costs, and mortality (P < 0.001). Logistic regression analysis demonstrated independent predictors of aspiration to include advanced age (≥65 yr), male sex, congestive heart failure, coagulopathy, neuropsychiatric disorders, and weight loss (P < 0.001).

CONCLUSION

We demonstrated an overall incidence of 5.3 cases of aspiration per 1000 cervical procedures. Patients most commonly affected by aspiration were older males with greater comorbidity. Hospital courses complicated by aspiration had greater length of stay, costs, and mortality. Identification of patients with risk factors for aspiration may assist in early diagnosis and treatment to prevent further morbidity and mortality.

Aortic valve replacement: using a statewide cardiac surgical database identifies a procedural volume hinge point

BACKGROUND

Expanding therapies for aortic stenosis have focused on high-risk and inoperable patients, suggesting that an evaluation of outcomes of conventional aortic valve replacement (AVR) or AVR and coronary artery bypass grafting (CABG) is timely and warranted.

METHODS

Outcomes for 6,270 AVR (3,487) or AVR/CABG (2,783) procedures performed in Michigan (2008-2011) were analyzed using a statewide cardiothoracic surgical database. Hospital and surgeon volume-outcome relationships were assessed.

RESULTS

Independent predictors of early mortality (all p < 0.05) included age, female sex, predicted risk of mortality, and hospital volume, with a hinge point of a 4-year volume of 390 procedures (high-volume hospital [HVH], 2.41% versus low-volume hospital [LVH], 4.34%; p < 0.001). At this hinge point, observed to expected ratio (O/E) for operative mortality after AVR was lower in HVHs for patients with a predicted risk of mortality (PRoM) greater than 4.7%. In contrast, no surgeon-volume outcome relationship was identified, even when stratified by preoperative patient-risk profile. With respect to other measures, HVHs reported lower rates of prolonged ventilation (24.9% versus LVH, 30.9%; p < 0.001), postoperative transfusion (46.1% versus LVH, 59.0%; p < 0.001), pneumonia (6.6% versus LVH, 9.0%; p = 0.01), and multisystem organ failure (0.7% versus LVH, 1.8%; p = 0.012).

CONCLUSIONS

This population-based analysis suggests that volume-outcome relationships exist for AVR. The predominant effect on mortality appears based on the setting of the procedure and occurs primarily in the high-risk patient. These results provide an opportunity to review approaches for high-risk patients undergoing AVR, including resource availability and system experience as the spectrum of treatment options expands to transcatheter therapies.

Predictors of resource utilization in transsphenoidal surgery for Cushing disease

Object

The short-term cost associated with subspecialized surgical care is an increasingly important metric and economic concern. This study sought to determine factors associated with hospital charges in patients undergoing transsphenoidal surgery for Cushing disease in an effort to identify the drivers of resource utilization.

Methods

The authors analyzed the Nationwide Inpatient Sample (NIS) hospital discharge database from 2007 to 2009 to determine factors that influenced hospital charges in patients who had undergone transsphenoidal surgery for Cushing disease. The NIS discharge database approximates a 20% sample of all inpatient admissions to nonfederal US hospitals. A multistep regression model was developed that adjusted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications.

Results

In 116 hospitals, 454 transsphenoidal operations were performed. The mean hospital charge was $48,272 ± $32,060. A multivariate regression model suggested that the primary driver of resource utilization was length of stay (LOS), followed by surgeon volume, hospital characteristics, and postoperative complications. A 1% increase in LOS increased hospital charges by 0.60%. Patient charges were 13% lower when performed by high-volume surgeons compared with low-volume surgeons and 22% lower in large hospitals compared with small hospitals. Hospital charges were 12% lower in cases with no postoperative neurological complications. The proposed model accounted for 46% of hospital charge variance.

Conclusions

This analysis of hospital charges in transsphenoidal surgery for Cushing disease suggested that LOS, hospital characteristics, surgeon volume, and postoperative complications are important predictors of resource utilization. These findings may suggest opportunities for improvement.

Teaching hospital five-year mortality trends in the wake of duty hour reforms

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined.

OBJECTIVE

To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform.

DESIGN

Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site.

PATIENTS

Medicare patients (n = 13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery.

MAIN MEASURE

All-location mortality within 30 days of hospital admission.

KEY RESULTS

In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1-3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93-0.94]); Post5 (OR 0.87, [0.82-0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85-0.96]).

CONCLUSIONS

Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded.

Comorbidities and perioperative complications in HIV-positive patients undergoing primary total hip and knee arthroplasty

BACKGROUND

Highly active antiretroviral therapy has prolonged the lifespan of individuals infected with human immunodeficiency virus (HIV). We hypothesized that the number of primary total joint arthroplasties performed in this population has been increasing and that HIV infection is not an independent risk factor for postoperative complications.

METHODS

The Nationwide Inpatient Sample for the years 2000 through 2008 was queried to identify patients who underwent primary total joint arthroplasty. HIV, comorbidities, and complications were identified with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Data were analyzed with use of multivariate logistic regression, the Pearson chi-square test, and the Mann-Kendall trend test.

RESULTS

Of the estimated 5,681,024 admissions for primary total hip and knee arthroplasty in the United States during this period, 8229 (0.14%) were in patients who had HIV. Compared with HIV-negative patients (controls), infected patients were more likely to be younger, be male, and have a history of osteonecrosis, liver disease, drug use, and coagulopathy. The number of total hip and total knee arthroplasties in HIV-positive patients increased from 2000 to 2008 (p &lt; 0.05). Seventy-nine percent (6499) of the total joint arthroplasties in the HIV-positive patients involved the hip. Compared with HIV-negative patients undergoing total hip arthroplasty, HIV-positive patients were more likely to develop acute renal failure (1.3% compared with 0.8%, p = 0.04), develop a wound infection (0.6% compared with 0.3%, p = 0.02), and undergo postoperative irrigation and debridement (0.2% compared with 0.1%, p = 0.01). They were less likely to have a myocardial infarction (0.4% compared with 0.9%, p = 0.04). There was no difference in total complications (8.3% compared with 7.8%, p = 0.52). Similarly, there was no difference in total complications in patients undergoing total knee arthroplasty (7.8% compared with 8.0%, p = 0.76). HIV was not an independent risk factor for complications in total hip arthroplasty (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.95 to 1.47) or total knee arthroplasty (OR, 0.78; 95% CI, 0.49 to 1.25).

CONCLUSIONS

The incidence of primary total joint arthroplasty in HIV-positive patients has been increasing. These patients were at slightly higher risk of certain immediate postoperative complications because of a higher rate of medical comorbidities. HIV infection was not an independent risk factor for the total rate of perioperative complications.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Overuse of preoperative cardiac stress testing in medicare patients undergoing elective noncardiac surgery

OBJECTIVE

To determine the frequency and predictors of cardiac stress testing before elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation.

BACKGROUND

The American College of Cardiology/American Heart Association guidelines indicate that patients without class I (American Heart Association high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery.

METHODS

We used 5% Medicare inpatient claims data (1996-2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urological, or orthopedic procedures (N = 211,202). We examined the use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N = 74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing.

RESULTS

Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N = 2803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (P < 0.0001). A multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female sex [odds ratio (OR) 1.11; 95% CI: 1.02-1.21], presence of other comorbidities [OR 1.22; 95% confidence interval (CI): 1.09-1.35], high-risk procedure (OR 2.42; 95% CI: 2.04-2.89), and larger hospital size (OR 1.17; 95% CI: 1.03-1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR 1.24; 95% CI: 1.05-1.45) were also more likely to receive stress tests.

CONCLUSIONS

In a 5% sample of Medicare claims data, 2803 patients underwent preoperative stress testing without any indications. When these results were applied to the entire Medicare population, we estimated that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications has increased significantly over time.

Interspinous spacers compared with decompression or fusion for lumbar stenosis: complications and repeat operations in the Medicare population

STUDY DESIGN

Retrospective cohort analysis of Medicare claims for 2006-2009.

OBJECTIVE

To examine whether interspinous distraction procedures are used selectively in patients with more advanced age or comorbidity, and whether they are associated with fewer complications, lower costs, and less revision surgery than laminectomy or fusion surgery.

SUMMARY OF BACKGROUND DATA

A manufacturer-sponsored randomized trial suggested an advantage of interspinous spacer surgery compared with nonsurgical care, but there are few comparisons with other surgical procedures. Furthermore, there are few population-based data evaluating patterns of use of these devices.

METHODS

We used Medicare inpatient claims data to compare age and comorbidity for patients with spinal stenosis undergoing surgery (n = 99,084) with (1) an interspinous process spacer alone; (2) laminectomy and a spacer; (3) decompression alone; or (4) lumbar fusion (1-2 level). We also compared these 4 groups for cost of surgery and rates of revision surgery, major medical complications, wound complications, mortality, and 30-day readmission rates.

RESULTS

Patients who received spacers were older than those undergoing decompression or fusion, but had little evidence of greater comorbidity. Patients receiving a spacer alone had fewer major medical complications than those undergoing decompression or fusion surgery (1.2% vs. 1.8% and 3.3%, respectively), but had higher rates of further inpatient lumbar surgery (16.7% vs. 8.5% for decompression and 9.8% for fusion at 2 yr). Hospital payments for spacer surgery were greater than those for decompression alone but less than for fusion procedures. These associations persisted in multivariate models adjusting for patient age, sex, comorbidity score, and previous hospitalization.

CONCLUSION

Compared with decompression or fusion, interspinous distraction procedures pose a trade-off in outcomes: fewer complications for the index operation, but higher rates of revision surgery. This information should help patients make more informed choices, but further research is needed to define optimal indications for these new devices.

LEVEL OF EVIDENCE

4.

Teaching hospital financial status and patient outcomes following ACGME duty hour reform

OBJECTIVE

To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

DATA SOURCES/STUDY SETTING

Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

STUDY DESIGN

Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).

PRINCIPAL FINDINGS

All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).

CONCLUSIONS

The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view

INTRODUCTION

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

METHODS

Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

RESULTS

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

CONCLUSION

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Outcomes of nails versus plates for humeral shaft fractures: a Medicare cohort study

OBJECTIVES

This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality.

DESIGN/SETTING

Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed.

PATIENTS/INTERVENTION

Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures.

MAIN OUTCOME MEASUREMENT

The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards.

RESULTS

We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality.

CONCLUSIONS

Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality.

LEVEL OF EVIDENCE

: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of radical cytoreductive surgery on omission and delay of chemotherapy for advanced-stage ovarian cancer

OBJECTIVE

Cytoreductive surgery is associated with extensive morbidity and may delay chemotherapy. We examined the associations among cytoreduction, perioperative complications, and delay or omission of chemotherapy.

METHODS

Women aged 65 years or older with stage III-IV ovarian cancer who were treated with surgery from 1991-2005 and recorded in the Surveillance, Epidemiology, and End Results-Medicare database were examined. We estimated the influence of extended cytoreduction as well as the occurrence of major perioperative complications on receipt and timing of chemotherapy and survival.

RESULTS

Among 3,991 patients, 479 (12%) failed to receive chemotherapy. Of those treated with chemotherapy, 2,527 (72%) initiated treatment within 6 weeks of surgery, 838 (24%) within 6-12 weeks, and 147 (4%) more than 12 weeks after surgery. In a multivariable model, older patients, those with comorbidities, mucinous tumors, and stage IV neoplasms were more likely not to receive chemotherapy (P<.05). Extended cytoreduction and the occurrence of postoperative complications were not associated with omission of chemotherapy but were associated with chemotherapy delay. For every 14 patients who underwent one extended procedure and for every 13 who had two extended procedures, one patient had a delay in receipt of chemotherapy. For every 14 patients who had one complication and for every four who had two complications, one patient had a delay in receipt of chemotherapy. The occurrence of more than two perioperative complications (hazard ratio 1.31, 95% confidence interval [CI] 1.15-1.49) and initiation of chemotherapy more than 12 weeks after surgery (hazard ratio 1.32, 95% CI 1.07-1.64) were associated with decreased survival.

CONCLUSION

Extended cytoreductive surgery and perioperative complications significantly delay initiation but do not increase the chance of omission of chemotherapy for women with ovarian cancer.

LEVEL OF EVIDENCE

II.

Are pediatric quality care measures too stringent?

INTRODUCTION

We aimed to demonstrate the application of national pediatric quality measures, derived from claims-based data, for use with electronic medical record data, and determine the extent to which rates differ if specifications were modified to allow for flexibility in measuring receipt of care.

METHODS

We reviewed electronic medical record data for all patients up to 15 years of age with ≥1 office visit to a safety net family medicine clinic in 2010 (n = 1544). We assessed rates of appropriate well-child visits, immunizations, and body mass index (BMI) documentation, defined strictly by national guidelines versus by guidelines with clinically relevant modifications.

RESULTS

Among children aged <3 years, 52.4% attended ≥6 well-child visits by the age of 15 months; 60.8% had ≥6 visits by age 2 years. Less than 10% completed 10 vaccination series before their second birthday; with modifications, 36% were up to date. Among children aged 3 to 15 years, 63% had a BMI percentile recorded; 91% had BMI recorded within 36 months of the measurement year.

CONCLUSIONS

Applying relevant modifications to national quality measure definitions captured a substantial number of additional services. Strict adherence to measure definitions might miss the true quality of care provided, especially among populations that may have sporadic patterns of care utilization.

Population-based estimates of transbronchial lung biopsy utilization and complications

BACKGROUND

Little is known about trends in the utilization or complication rates of transbronchial lung biopsy, particularly in community hospitals.

METHODS

We used the Healthcare Cost and Utilization Project Florida State Inpatient and State Ambulatory Surgical Databases to assess trends in transbronchial lung biopsy utilization in adults from 2000 to 2009. We subsequently calculated population based estimates of complications associated with transbronchial lung biopsy (iatrogenic pneumothorax and procedure-related hemorrhage) and identified characteristics associated with complications.

RESULTS

From 2000 to 2009, the age-adjusted rate of transbronchial biopsies per 100,000 adults in Florida decreased by 25% from 74 to 55 (p < 0.0001), despite stability in the overall utilization of bronchoscopy. Analysis of 82,059 procedures revealed that complications associated with transbronchial biopsy were uncommon and stable over the study period, with 0.97% (95% CI 0.94-1.01%) of procedures complicated by pneumothorax, 0.55% (95% CI 0.52-0.58%) by pneumothorax requiring chest tube placement, and 0.58% (95% CI 0.55-0.61%) by procedure-related hemorrhage. Patients with COPD (OR 1.51, 95% CI 1.31-1.75) and women (OR 1.32, 95% CI 1.15-1.52) were at increased risk for pneumothorax, while renal failure (OR 2.85, 95% CI 2.10-3.87), cirrhosis (OR 2.31, 95% CI 1.18-4.52), older age (OR 1.17, 95% CI 1.09-1.25) and female sex (OR 1.40, 95% CI 1.17-1.68) were associated with higher risk of procedure-related hemorrhage.

CONCLUSIONS

Utilization of transbronchial lung biopsy is decreasing relative to the overall use of bronchoscopy. Nevertheless, it remains a safe procedure with low risk of complications.

Identifying paediatric nursing-sensitive outcomes in linked administrative health data

Background

There is increasing interest in the contribution of the quality of nursing care to patient outcomes. Due to different casemix and risk profiles, algorithms for administrative health data that identify nursing-sensitive outcomes in adult hospitalised patients may not be applicable to paediatric patients. The study purpose was to test adult algorithms in a paediatric hospital population and make amendments to increase the accuracy of identification of hospital acquired events. The study also aimed to determine whether the use of linked hospital records improved the likelihood of correctly identifying patient outcomes as nursing sensitive rather than being related to their pre-morbid conditions.

Methods

Using algorithms developed by Needleman et al. (2001), proportions and rates of records that identified nursing-sensitive outcomes for pressure ulcers, pneumonia and surgical wound infections were determined from administrative hospitalisation data for all paediatric patients discharged from a tertiary paediatric hospital in Western Australia between July 1999 and June 2009. The effects of changes to inclusion and exclusion criteria for each algorithm on the calculated proportion or rate in the paediatric population were explored. Linked records were used to identify comorbid conditions that increased nursing-sensitive outcome risk. Rates were calculated using algorithms revised for paediatric patients.

Results

Linked records of 129,719 hospital separations for 79,016 children were analysed. Identification of comorbid conditions was enhanced through access to prior and/or subsequent hospitalisation records (43% of children with pressure ulcers had a form of paralysis recorded only on a previous admission). Readmissions with a surgical wound infection were identified for 103 (4.8/1,000) surgical separations using linked data. After amendment of each algorithm for paediatric patients, rates of pressure ulcers and pneumonia reduced by 53% and 15% (from 1.3 to 0.6 and from 9.1 to 7.7 per 10,000 patient days) respectively, and an 84% increase in the proportion of surgical wound infection (from 5.7 to 10.4 per 1,000 separations).

Conclusions

Algorithms for nursing-sensitive outcomes used in adult populations have to be amended before application to paediatric populations. Using unlinked individual hospitalisation records to estimate rates of nursing-sensitive outcomes is likely to result in inaccurate rates.

Comparative effectiveness of low-molecular-weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

BACKGROUND

Both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial.

OBJECTIVE

To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients.

DESIGN

Retrospective cohort.

SETTING

Three hundred thirty-three acute care facilities in 2004-2005.

PATIENTS

Adults with 4 common medical diagnoses considered to carry moderate-to-high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤ 2 days. VTE prophylaxis was assessed from billing data.

INTERVENTION

None.

MEASUREMENTS

VTE, major bleeding or heparin-induced thrombocytopenia, mortality, and cost.

RESULTS

Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (<0.2%). In analysis adjusted for the propensity for UFH and other covariates, patients treated with UFH had an odds ratio for VTE of 1.04 (95% confidence interval [CI] 0.76 to 1.43) compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was 1.14 (95% CI 0.72 to 1.81). Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% CI 0.50 to 5.33), adjusted odds of complications followed by stopping prophylaxis were 2.84 (95% CI 1.43 to 45.66), and adjusted cost ratio was 0.97 (95% CI 0.90 to 1.05).

CONCLUSIONS

For VTE prophylaxis, the effectiveness and cost of LMWH and UFH are similar, but LMWH is associated with fewer complications.

Feasibility of evaluating the CHIPRA care quality measures in electronic health record data

The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) includes provisions for identifying standardized pediatric care quality measures. These 24 "CHIPRA measures" were designed to be evaluated by using claims data from health insurance plan populations. Such data have limited ability to evaluate population health, especially among uninsured people. The rapid expansion of data from electronic health records (EHRs) may help address this limitation by augmenting claims data in care quality assessments. We outline how to operationalize many of the CHIPRA measures for application in EHR data through a case study of a network of >40 outpatient community health centers in 2009-2010 with a single EHR. We assess the differences seen when applying the original claims-based versus adapted EHR-based specifications, using 2 CHIPRA measures (Chlamydia screening among sexually active female patients; BMI percentile documentation) as examples. Sixteen of the original CHIPRA measures could feasibly be evaluated in this dataset. Three main adaptations were necessary (specifying a visit-based population denominator, calculating some pregnancy-related factors by using EHR data, substituting for medication dispense data). Although it is feasible to adapt many of the CHIPRA measures for use in outpatient EHR data, information is gained and lost depending on how numerators and denominators are specified. We suggest first steps toward application of the CHIPRA measures in uninsured populations, and in EHR data. The results highlight the importance of considering the limitations of the original CHIPRA measures in care quality evaluations.

Hospital and surgeon variation in complications and repeat surgery following incident lumbar fusion for common degenerative diagnoses

OBJECTIVE

To identify factors that account for variation in complication rates across hospitals and surgeons performing lumbar spinal fusion surgery.

DATA SOURCES

Discharge registry including all nonfederal hospitals in Washington State from 2004 to 2007.

STUDY DESIGN

We identified adults (n = 6,091) undergoing an initial inpatient lumbar fusion for degenerative conditions. We identified whether each patient had a subsequent complication within 90 days. Logistic regression models with hospital and surgeon random effects were used to examine complications, controlling for patient characteristics and comorbidity.

PRINCIPAL FINDINGS

Complications within 90 days of a fusion occurred in 4.8 percent of patients, and 2.2 percent had a reoperation. Hospital effects accounted for 8.8 percent of the total variability, and surgeon effects account for 14.4 percent. Surgeon factors account for 54.5 percent of the variation in hospital reoperation rates, and 47.2 percent of the variation in hospital complication rates. The discretionary use of operative features, such as the inclusion of bone morphogenetic proteins, accounted for 30 and 50 percent of the variation in surgeons' reoperation and complication rates, respectively.

CONCLUSIONS

To improve the safety of lumbar spinal fusion surgery, quality improvement efforts that focus on surgeons' discretionary use of operative techniques may be more effective than those that target hospitals.

A systematic review of validated methods for identifying venous thromboembolism using administrative and claims data

BACKGROUND

Venous thromboembolism (VTE) is a serious complication. Large claims databases can potentially identify the effects that medications have on VTE. The purpose of this study is to evaluate the evidence supporting the validity of VTE codes.

METHODS

A search of MEDLINE database is supplemented by manual searches of bibliographies of key relevant articles. We selected all studies in which a claim code was validated against a medical record. We reported the positive predictive value (PPV) for the VTE claim compared to the medical record.

RESULTS

Our search strategy yielded 345 studies, of which only 19 met our eligibility criteria. All of the studies reported on ICD-9 codes, but only two studies reported on pharmacy codes, and one study reported on procedure codes. The highest PPV (65%-95%) was reported for the combined use of ICD-9 codes 415 (pulmonary embolism), 451, and 453 (deep vein thrombosis) as a VTE event. If a specific event like DVT (PPV 24%-92%) or PE (PPV 31%-97%) was evaluated, the PPV was lower than when the combined events were examined. Studies that included patients after orthopedic surgery reported the highest PPV (96%-100%).

CONCLUSIONS

The use of ICD-9 415, 451, and 453 are appropriate for the identification of VTE in claims databases. The codes performed best when codes were evaluated in patients at higher risk of VTE.

Quantifying the incremental cost of complications associated with mitral valve surgery in the United States

OBJECTIVE

The goal of this study was to quantify the net increase in resource use associated with complications after isolated mitral valve surgery.

METHODS

Deidentified patient-level claims data on a random sample of mitral valve operations performed in the United States from January 1, 2006, to December 31, 2007, were obtained from the National Inpatient Sample (n = 16,788). Patients with major concomitant cardiac procedures were excluded from the analysis for a net sample size of 6297 patients. Risk-adjusted median total hospital costs and length of stay were analyzed by major complications, including pneumonia, sepsis, stroke, renal failure requiring hemodialysis, cardiac tamponade, myocardial infarction, gastrointestinal bleed, and venous thromboembolism.

RESULTS

There were a total of 1323 complication events that occurred in 1089 patients. The most common complication was pneumonia (n = 346, 5.5%), which was associated with a $29,692 increase in hospital costs and a 10.2-day increase in median length of stay (P < .001). The most costly complication was cardiac tamponade, which resulted in an increase in hospital cost of $56,547 and an increase in length of stay of 19.3 days (P < .001). There was a stepwise association between the hospital costs and length of stay and the number of complications per patient (P < .001). There was also a significant association between the discharge location and the occurrence of a complication, with 25% more patients who underwent routine home discharge when there were no complications (P < .001).

CONCLUSIONS

In patients undergoing isolated mitral valve surgery, postoperative complications were associated with significant increases in mortality, hospital costs, and length of stay, as well as with discharge location. With growing national attention to improving quality and containing costs, it is important to understand the nature and impact of complications on outcomes and costs.

Impact of age, injury severity score, and medical comorbidities on early complications after fusion and halo-vest immobilization for C2 fractures in older adults: a propensity score matched retrospective cohort study

STUDY DESIGN

Propensity score matched retrospective cohort study.

OBJECTIVE

To report early complication rates and associated risk factors in patients with C2 fractures who underwent fusion or halo immobilization.

SUMMARY OF BACKGROUND DATA

There is limited data on the impact of age, injury severity score, and medical comorbidities on overall complication rates from surgical fixation versus halo-vest immobilization of C2 fractures.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2008 was queried to identify cohorts of adult patients (age ≥ 18 years) with C2 fractures without spinal cord injury who were treated with either fusion or halo-vest immobilization. Complication rates, hospital length of stay, and costs were compared in a propensity score matched sample. Multivariate analysis was used to identify predictors of in-hospital complications.

RESULTS

A total of 3758 patients (1627 fusion and 2131 halo) were identified. Fusion was associated with greater overall complication rates (20.2% vs. 10.1%, P < 0.0001), increased length of stay (8.9 d vs. 6.4 d, P < 0.0001), higher charges ($80,000 vs. $41,000, P < 0.0001), but a lower rate of nonroutine discharge (52.6% vs. 62.6%, P < 0.0001). There was no difference in mortality between the fusion group (2.75%) and the halo group (3.33%). Age, injury score, and comorbidity increased complication rates by a similar degree (odds ratio) in both cohorts. Patients aged 80 years and older were 3.5 times more likely to have a complication than those younger than 60 years.

CONCLUSION

Fusion patients had greater overall complication rates, increased length of stay, and greater resource utilization but were discharged home in a greater proportion. Both fusion and halo were associated with significant (more than 3-fold) increase in complication rates in elderly patients aged 80 years or older. Given the similar mortality rate between the fusion group and the halo group and the higher cost and complication rate in the fusion group, our study supports the use of halo-vest immobilization in patients where operative therapy is contraindicated.