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

Hospital surgical volume, utilization, costs and outcomes of retroperitoneal lymph node dissection for testis cancer

Objectives. Retroperitoneal lymph node dissection (RPLND) outcomes for testis cancer originate mostly from single-center series. We characterized population-based utilization, costs, and outcomes and assessed whether higher volume affects outcomes. Methods and Materials. Using the US Nationwide Inpatient Sample from 2001-2008, we identified 993 RPLND and used propensity score methods to assess utilization, costs, and inpatient outcomes based on hospital surgical volume. Results. 51.6% of RPLND were performed at hospitals where there were two or fewer cases per year. RPLND was more commonly performed at large urban teaching hospitals, where men were younger, more likely to be white and earning incomes exceeding the 50th percentile (all P ≤ .05). Higher hospital volumes were associated with fewer complications and more routine home discharges (all P ≤ .047). However, higher volume hospitals had more transfusions (P = .004) and incurred $1,435 more in median costs (P < .001). Limitations include inability to adjust for tumor characteristics and absence of outpatient outcomes. Conclusions. Sociodemographic differences exist between high versus low volume RPLND hospitals. Although higher volume hospitals had more transfusions and higher costs, perhaps due to more complex cases, they experienced fewer complications. However, most RPLND are performed at hospitals where there were two or fewer cases per year.

Comparative analysis of outcomes and costs following open radical cystectomy versus robot-assisted laparoscopic radical cystectomy: results from the US Nationwide Inpatient Sample

BACKGROUND

Although robot-assisted laparoscopic radical cystectomy (RARC) was first reported in 2003 and has gained popularity, comparisons with open radical cystectomy (ORC) are limited to reports from high-volume referral centers.

OBJECTIVE

To compare population-based perioperative outcomes and costs of ORC and RARC.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective observational cohort study using the US Nationwide Inpatient Sample to characterize 2009 RARC compared with ORC use and outcomes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Propensity score methods were used to compare inpatient morbidity and mortality, lengths of stay, and costs.

RESULTS AND LIMITATIONS

We identified 1444 ORCs and 224 RARCs. Women were less likely to undergo RARC than ORC (9.8% compared with 15.5%, p = 0.048), and 95.7% of RARCs and 73.9% of ORCs were performed at teaching hospitals (p<0.001). In adjusted analyses, subjects undergoing RARC compared with ORC experienced fewer inpatient complications (49.1% and 63.8%, p = 0.035) and fewer deaths (0% and 2.5%, p<0.001). RARC compared with ORC was associated with lower parenteral nutrition use (6.4% and 13.3%, p = 0.046); however, there was no difference in length of stay. RARC compared with ORC was $3797 more costly (p = 0.023). Limitations include retrospective design, absence of tumor characteristics, and lack of outcomes beyond hospital discharge.

CONCLUSIONS

RARC is associated with lower parenteral nutrition use and fewer inpatient complications and deaths. However, lengths of stay are similar, and the robotic approach is significantly more costly.

Composite measures for rating hospital quality with major surgery

OBJECTIVE

To assess the value of a novel composite measure for identifying the best hospitals for major procedures.

DATA SOURCE

We used national Medicare data for patients undergoing five high-risk surgical procedures between 2005 and 2008.

STUDY DESIGN

For each procedure, we used empirical Bayes techniques to create a composite measure combining hospital volume, risk-adjusted mortality with the procedure of interest, risk-adjusted mortality with other related procedures, and other variables. Hospitals were ranked based on 2005-2006 data and placed in one of three groups: 1-star (bottom 20 percent), 2-star (middle 60 percent), and 3-star (top 20 percent). We assessed how well these ratings forecasted risk-adjusted mortality rates in the next 2 years (2007-2008), compared to other measures.

PRINCIPAL FINDINGS

For all five procedures, the composite measures based on 2005-2006 data performed well in predicting future hospital performance. Compared to 1-star hospitals, risk-adjusted mortality was much lower at 3-star hospitals for esophagectomy (6.7 versus 14.4 percent), pancreatectomy (4.7 versus 9.2 percent), coronary artery bypass surgery (2.6 versus 5.0 percent), aortic valve replacement (4.5 versus 8.5 percent), and percutaneous coronary interventions (2.4 versus 4.1 percent). Compared to individual surgical quality measures, the composite measures were better at forecasting future risk-adjusted mortality. These measures also outperformed the Center for Medicare and Medicaid Services (CMS) Hospital Compare ratings.

CONCLUSION

Composite measures of surgical quality are very effective at predicting hospital mortality rates with major procedures. Such measures would be more informative than existing quality indicators in helping patients and payers identify high-quality hospitals with specific procedures.

Use, costs and comparative effectiveness of robotic assisted, laparoscopic and open urological surgery

PURPOSE

Although robotic assisted laparoscopic surgery has been aggressively marketed and rapidly adopted, there are few comparative effectiveness studies that support its purported advantages compared to open and laparoscopic surgery. We used a population based approach to assess use, costs and outcomes of robotic assisted laparoscopic surgery vs laparoscopic surgery and open surgery for common robotic assisted urological procedures.

MATERIALS AND METHODS

From the Nationwide Inpatient Sample we identified the most common urological robotic assisted laparoscopic surgery procedures during the last quarter of 2008 as radical prostatectomy, nephrectomy, partial nephrectomy and pyeloplasty. Robotic assisted laparoscopic surgery, laparoscopic surgery and open surgery use, costs and inpatient outcomes were compared using propensity score methods.

RESULTS

Robotic assisted laparoscopic surgery was performed for 52.7% of radical prostatectomies, 27.3% of pyeloplasties, 11.5% of partial nephrectomies and 2.3% of nephrectomies. For radical prostatectomy robotic assisted laparoscopic surgery was more prevalent than open surgery among white patients in high volume, urban hospitals (all p≤0.015). Geographic variations were found in the use of robotic assisted laparoscopic surgery vs open surgery. Robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery were associated with shorter length of stay for all procedures, with robotic assisted laparoscopic surgery being the shortest for radical prostatectomy and partial nephrectomy (all p<0.001). For most procedures robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery resulted in fewer deaths, complications, transfusions and more routine discharges. However, robotic assisted laparoscopic surgery was more costly than laparoscopic surgery and open surgery for most procedures.

CONCLUSIONS

While robotic assisted and laparoscopic surgery are associated with fewer deaths, complications, transfusions and shorter length of hospital stay compared to open surgery, robotic assisted laparoscopic surgery is more costly than laparoscopic and open surgery. Additional studies are needed to better delineate the comparative and cost-effectiveness of robotic assisted laparoscopic surgery relative to laparoscopic surgery and open surgery.

Use of bone morphogenetic proteins in spinal fusion surgery for older adults with lumbar stenosis: trends, complications, repeat surgery, and charges

STUDY DESIGN

Retrospective cohort study of Medicare claims.

OBJECTIVE

Examine trends and patterns in the use of bone morphogenetic proteins (BMP) in surgery for lumbar stenosis; compare complications, reoperation rates, and charges for patients undergoing lumbar fusion with and without BMP.

SUMMARY OF BACKGROUND DATA

Small, randomized trials have demonstrated higher rates of solid fusion with BMP than with allograft bone alone, with few complications and, in some studies, reduced rates of revision surgery. However, complication and reoperation rates from large population-based cohorts in routine care are unavailable.

METHODS

We identified patients with a primary diagnosis of lumbar stenosis who had fusion surgery in 2003 or 2004 (n = 16,822). We identified factors associated with BMP use: major medical complications during the index hospitalization, rates of rehospitalization within 30 days, and rates of reoperation within 4 years of follow-up (through 2008).

RESULTS

Use of BMP increased rapidly, from 5.5% of fusion cases in 2003 to 28.1% of fusion cases in 2008. BMP use was greater among patients with previous surgery and among those having complex fusion procedures (combined anterior and posterior approach, or greater than 2 disc levels). Major medical complications, wound complications, and 30-day rehospitalization rates were nearly identical with or without BMP. Reoperation rates were also very similar, even after stratifying by previous surgery or surgical complexity, and after adjusting for demographic and clinical features. On average, adjusted hospital charges for operations involving BMP were about $15,000 more than hospital charges for fusions without BMP, though reimbursement under Medicare's Diagnosis-Related Group system averaged only about $850 more. Significantly fewer patients receiving BMP were discharged to a skilled nursing facility (15.9% vs. 19.0%, P < 0.001).

CONCLUSION

In this older population having fusion surgery for lumbar stenosis, uptake of BMP was rapid, and greatest among patients with prior surgery or having complex fusion procedures. BMP appeared safe in the perioperative period, with no increase in major medical complications. Use of BMP was associated with greater hospital charges but fewer nursing home discharges, and was not associated with reduced likelihood of reoperation.

Test result-based sampling: an efficient design for estimating the accuracy of patient safety indicators

OBJECTIVE

Accuracy studies of Patient Safety Indicators (PSIs) are critical but limited by the large samples required due to low occurrence of most events. We tested a sampling design based on test results (verification-biased sampling [VBS]) that minimizes the number of subjects to be verified.

METHODS

We considered 3 real PSIs, whose rates were calculated using 3 years of discharge data from a university hospital and a hypothetical screen of very rare events. Sample size estimates, based on the expected sensitivity and precision, were compared across 4 study designs: random and VBS, with and without constraints on the size of the population to be screened.

RESULTS

Over sensitivities ranging from 0.3 to 0.7 and PSI prevalence levels ranging from 0.02 to 0.2, the optimal VBS strategy makes it possible to reduce sample size by up to 60% in comparison with simple random sampling. For PSI prevalence levels below 1%, the minimal sample size required was still over 5000.

CONCLUSIONS

Verification-biased sampling permits substantial savings in the required sample size for PSI validation studies. However, sample sizes still need to be very large for many of the rarer PSIs.

Complications after prostate biopsy: data from SEER-Medicare

PURPOSE

More than 1 million prostate biopsies are performed annually among Medicare beneficiaries. We determined the risk of serious complications requiring hospitalization. We hypothesized that with emerging multidrug resistant organisms there may be an increasing risk of infectious complications.

MATERIALS AND METHODS

In a 5% random sample of Medicare participants in SEER (Surveillance, Epidemiology and End Results) regions from 1991 to 2007 we compared 30-day hospitalization rates and ICD-9 primary diagnosis codes for admissions between 17,472 men who underwent prostate biopsy and a random sample of 134,977 controls. Multivariate logistic and Poisson regression were used to examine the risk and predictors of serious infectious and noninfectious complications with time.

RESULTS

The 30-day hospitalization rate was 6.9% within 30 days of prostate biopsy, which was substantially higher than the 2.7% in the control population. After adjusting for age, race, SEER region, year and comorbidities prostate biopsy was associated with a 2.65-fold (95% CI 2.47-2.84) increased risk of hospitalization within 30 days compared to the control population (p <0.0001). The risk of infectious complications requiring hospitalization after biopsy was significantly greater in more recent years (p(trend) = 0.001). Among men undergoing biopsy, later year, nonwhite race and higher comorbidity scores were significantly associated with an increased risk of infectious complications.

CONCLUSIONS

The risk of hospitalization within 30 days of prostate biopsy was significantly higher than in a control population. Infectious complications after prostate biopsy have increased in recent years while the rate of serious noninfectious complications is relatively stable. Careful patient selection for prostate biopsy is essential to minimize the potential harms.

The influence of surgical volume on morbidity and mortality of radical hysterectomy for cervical cancer

OBJECTIVE

We examined the influence of physician and hospital volume on the morbidity and mortality of radical hysterectomy for cervical cancer.

STUDY DESIGN

Women who underwent radical hysterectomy for cervical cancer between 2003 and 2007 were examined. The effect of surgeon and hospital volume on morbidity and mortality was examined using multivariable generalized estimating equations.

RESULTS

A total of 1536 women who underwent radical hysterectomy were identified. Patients treated by high-volume surgeons had fewer medical complications (odds ratio, 0.55; 95% confidence interval, 0.34-0.88) and shorter lengths of stay (odds ratio, 0.49; 95% confidence interval, 0.25-0.98). After adjustment for case mix and surgeon volume, hospital volume had no independent effect on any of the variables of interest.

CONCLUSION

High-volume surgeons have fewer postoperative medical complications, shorter lengths of stay, and lower transfusion requirements. Hospital volume appears to have only a minor influence on outcomes after radical hysterectomy.

Assessment of variation in live donor kidney transplantation across transplant centers in the United States

BACKGROUND

Transplant centers vary in the proportion of kidney transplants performed using live donors. Clinical innovations that facilitate live donation may drive this variation.

METHODS

We assembled a cohort of renal transplant candidates at 194 US centers using registry data from 1999 to 2005. We measured magnitude of live donor kidney transplantation (LDKTx) through development of a standardized live donor transplantation ratio (SLDTR) at each center that accounted for center population differences. We examined associations between center characteristics and the likelihood that individual transplant candidates underwent LDKTx. To identify practices through which centers increase LDKTx, we also examined center characteristics associated with consistently being in the upper three quartiles of SLDTR.

RESULTS

The cohort comprised 148,168 patients, among whom 34,593 (23.3%) underwent LDKTx. In multivariable logistic regression, candidates had an increased likelihood of undergoing LDKTx at centers with greater use of "unrelated donors" (defined as nonspouses and nonfirst-degree family members of the recipient; odds ratio [OR] 1.31 for highest vs. lowest use; P=0.02) and at centers with programs to overcome donor-recipient incompatibility (OR 1.33; P=0.01). Centers consistently in the upper three SLDTR quartiles were also more likely to use "unrelated" donors (OR 8.30 per tertile of higher use; P<0.01), to have incompatibility programs (OR 4.79, P<0.01), and to use laparoscopic nephrectomy (OR 2.53 per tertile of higher use; P=0.02).

CONCLUSION

Differences in center population do not fully account for differences in the use of LDKTx. To maximize opportunities for LDKTx, centers may accept more unrelated donors and adopt programs to overcome biological incompatibility.

Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records

BACKGROUND

Because pulmonary nodules are found in up to 25% of patients undergoing computed tomography of the chest, the question of whether to perform biopsy is becoming increasingly common. Data on complications after transthoracic needle lung biopsy are limited to case series from selected institutions.

OBJECTIVE

To determine population-based estimates of risks for complications after transthoracic needle biopsy of a pulmonary nodule.

DESIGN

Cross-sectional analysis.

SETTING

The 2006 State Ambulatory Surgery Databases and State Inpatient Databases for California, Florida, Michigan, and New York from the Healthcare Cost and Utilization Project.

PATIENTS

15 865 adults who had transthoracic needle biopsy of a pulmonary nodule.

MEASUREMENTS

Percentage of biopsies complicated by hemorrhage, any pneumothorax, or pneumothorax requiring a chest tube, and adjusted odds ratios for these complications associated with various biopsy characteristics, calculated by using multivariate, population-averaged generalized estimating equations.

RESULTS

Although hemorrhage was rare, complicating 1.0% (95% CI, 0.9% to 1.2%) of biopsies, 17.8% (CI, 11.8% to 23.8%) of patients with hemorrhage required a blood transfusion. In contrast, the risk for any pneumothorax was 15.0% (CI, 14.0% to 16.0%), and 6.6% (CI, 6.0% to 7.2%) of all biopsies resulted in pneumothorax requiring a chest tube. Compared with patients without complications, those who experienced hemorrhage or pneumothorax requiring a chest tube had longer lengths of stay (P < 0.001) and were more likely to develop respiratory failure requiring mechanical ventilation (P = 0.020). Patients aged 60 to 69 years (as opposed to younger or older patients), smokers, and those with chronic obstructive pulmonary disease had higher risk for complications.

LIMITATIONS

Estimated risks may be inaccurate if coding of complications is incomplete. The analyzed databases contain little clinical detail (such as information on nodule characteristics or biopsy pathology) and cannot indicate whether performing the biopsy produced useful information.

CONCLUSION

Whereas hemorrhage is an infrequent complication of transthoracic needle lung biopsy, pneumothorax is common and often necessitates chest tube placement. These population-based data should help patients and physicians make more informed choices about whether to perform biopsy of a pulmonary nodule.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs and National Cancer Institute.

The effect of age on the morbidity of kidney surgery

PURPOSE

Previous reports of the morbidity of renal surgery have been primarily from academic tertiary referral centers and, thus, they may not reflect general clinical practice. We determined the effect of age and comorbidity on in-hospital surgical morbidity for radical and partial nephrectomy on a population level.

MATERIALS AND METHODS

Data were obtained from a Canadian national discharge abstract database. From April 1998 to March 2008 information was available on 20,286 radical and 4,292 partial nephrectomies. Complications were identified using specific ICD-9 and 10 diagnosis and procedure codes. Complication rates were estimated by procedure type and by various explanatory variables, including patient age and Charlson comorbidity score. Multivariate logistic regressions were constructed for radical and partial nephrectomy to determine associations between explanatory variables and complications.

RESULTS

Overall complications developed in 34.1% of radical and 34.3% of partial nephrectomy cases. Patients were more likely to have cardiac, respiratory, vascular and surgical complications after radical nephrectomy while they were more likely to experience genitourinary and nephrectomy specific complications after partial nephrectomy. On multivariate logistic regression after radical and partial nephrectomy complications increased with age and Charlson score. After adjusting for other covariates patients with a Charlson score of greater than 2 were approximately 6 times more likely to experience a complication than patients with a Charlson score of 0 for radical and partial nephrectomy (OR 6.22, 95% CI 5.18-7.48 and OR 5.68, 95% CI 3.72-8.66, respectively).

CONCLUSIONS

In our population based study radical nephrectomy and partial nephrectomy were associated with higher morbidity than previously reported, particularly in the elderly population and in patients with comorbidity.

Statewide and national impact of California's Staffing Law on pediatric cardiac surgery outcomes

OBJECTIVE

The objective of the study was to examine the impact of staffing ratios on risk-adjusted outcomes for pediatric cardiac surgery programs in California and relative to other states combined.

BACKGROUND

California performs 20% of the nation's pediatric cardiac surgery and is the only state with a nurse ratio law. Understanding the imposition of mandated ratios on pediatric outcomes is necessary to inform the debate about nurse staffing.

DATA SOURCES

Patient variables were extracted from the Healthcare Cost and Utilization Project Kids' Inpatient Database. The American Hospital Association database was used for institutional variables.

METHODS

Descriptive analyses were used to identify and describe patient, nursing, and hospital characteristics. Changes in nursing ratios and full-time equivalents (FTEs) between 2003 and 2006 were examined. Associations between nursing characteristics and each outcome variable were examined using general estimating equation models. The RACHS-1 (Risk Adjustment for Congenital Heart Surgery) risk adjustment method was used for mortality.

RESULTS

Hospitals in California significantly increased RN FTEs (P = .025) and RN ratios (P = .036) after enactment of AB 394 in 2006. Neither RN FTEs nor RN ratios were associated with mortality, complications, or resource utilization after risk adjustment. After the law, California's standardized mortality ratio (SMR) decreased more (33%) than in all other states combined (29%). Standardized complication ratio (SCR) increased by 5% but decreased by 5% for all other states combined, and the increase in charge differential ($53,443) was more than twice the increase ($23,119) for other states combined.

CONCLUSION

Hospitals in California made upward adjustments in nursing FTEs and ratios after enactment of AB 394. There was a substantial increase in California's charge differential, a decrease in SMR, and an increase in SCR after enactment of the legislation.

Excess Costs Attributable to Postoperative Complications

This article estimates excess costs associated with postoperative complications among inpatients treated in Veterans Health Administration (VA) hospitals. The authors conducted an observational study on 43,822 hospitalizations involving inpatient surgery in one of 104 VA hospitals during fiscal year 2007. Hospitalization-level cost regression analyses were performed to estimate the excess cost of each of 18 unique postoperative complications. The authors used generalized linear modeling techniques to account for the heavily skewed cost distribution. Costs were measured using an activity-based cost accounting system and complications were assessed based on medical chart review conducted by the VA ‘National Surgical Quality Improvement Program. The authors found excess costs associated with postoperative complications ranging from $8,338 for “superficial surgical site infection” to $29,595 for “failure to wean within 24 hours in the presence of respiratory complications.” The results obtained suggest that quality improvement efforts aimed at reducing postoperative complications can contribute significantly to lowering of hospital costs.

How valid is the AHRQ Patient Safety Indicator "postoperative physiologic and metabolic derangement"?

BACKGROUND

The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative physiologic and metabolic derangement (PMD) uses ICD-9-CM codes to screen for potentially preventable acute kidney injury (AKI) requiring dialysis plus diabetes-related complications after elective surgery. Data on PMD's accuracy in identifying true events are limited. We examined the indicator's positive predictive value (PPV) in the Veterans Health Administration (VA).

STUDY DESIGN

Trained abstractors reviewed medical records of 119 PSI software-flagged PMD cases. We calculated PPVs overall and separately for renal- and diabetes-related complications. We also examined false positives to determine reasons for incorrect identification, and true positives to determine PMD-related outcomes and risk factors.

RESULTS

Overall 75 cases were true positives (PPV 63%, 95% CI 54% to 72%); 73 of 104 AKI cases were true positives (PPV 70%, 60% to 79%); only 2 of 15 diabetes cases were true positives (PPV 13%, 2% to 40%). Of all false positives, 70% represented nonelective admissions and 23% had the complication present on admission. Of AKI true positives, 37% died and 26% were discharged on dialysis; 55% had chronic kidney disease (≥ stage 3) present on admission. Cardiac surgery represented the largest category of AKI-associated index procedures (30%). AKI was most commonly attributed to perioperative renal hypoperfusion (84% of true positives), followed by nephrotoxins (33%) including contrast (11%).

CONCLUSIONS

Due to its low PPV, we recommend removing diabetes complications from the indicator and focusing on AKI. PMD's PPV could be significantly improved by using present-on-admission codes, and specific to the VA, by introduction of admission status codes. Many PMD-identified cases appeared to be at high risk based on patient- and procedure-related factors. The degree to which such cases are truly preventable events requires further assessment.

How valid is the AHRQ Patient Safety Indicator "postoperative hemorrhage or hematoma"?

BACKGROUND

Postoperative hemorrhage or hematoma (PHH), an Agency for Healthcare Research and Quality Patient Safety Indicator, uses administrative data to detect cases of potentially preventable postsurgical bleeding requiring a reparative procedure. How accurately it identifies true events is unknown. We therefore determined PHH's positive predictive value.

STUDY DESIGN

Using Patient Safety Indicator software (v.3.1a) and fiscal year 2003-2007 discharge data from 28 Veterans Health Administration hospitals, we identified 112 possible cases of PHH. Based on medical record abstraction, we characterized cases as true (TPs) or false positives (FPs), calculated positive predictive value, and analyzed FPs to ascertain reasons for incorrect identification and TPs to determine PHH-associated clinical consequences and risk factors.

RESULTS

Eighty-four cases were TPs (positive predictive value, 75%; 95% CI, 66-83%); 63% had a hematoma diagnosis, 30% had a hemorrhage diagnosis, 7% had both. Reasons for FPs included events present on admission (29%); hemorrhage/hematoma identified and controlled during the original procedure rather than postoperatively (21%); or postoperative hemorrhage/hematoma that did not require a procedure (18%). Most TPs (82%) returned to the operating room for hemorrhage/hematoma management; 64% required blood products and 7% died in-hospital. The most common index procedures resulting in postoperative hemorrhage/hematoma were vascular (38%); 56% were performed by a physician-in-training (under supervision). We found no substantial association between physician training status or perioperative anticoagulant use and bleeding risk.

CONCLUSIONS

PHH's accuracy could be improved by coding enhancements, such as adopting present on admission codes or associating a timing factor with codes dealing with bleeding control. The ability of PHH to identify events representing quality of care problems requires additional evaluation.

How valid is the AHRQ Patient Safety Indicator "postoperative respiratory failure"?

BACKGROUND

The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative respiratory failure (PRF) uses administrative data to screen for potentially preventable respiratory failure after elective surgery based on a respiratory failure diagnosis or an intubation or ventilation procedure code. Data on PRF accuracy in identifying true events is scant; a recent study using University HealthSystem Consortium data found a positive predictive value (PPV) of 83%. We examined the indicator's PPV in the Veterans Health Administration.

STUDY DESIGN

We applied the Patient Safety Indicator software (v.3.1a) to fiscal year 2003-2007 VA discharge data. Trained abstractors reviewed medical records of 112 software-flagged PRF cases. We calculated the PPV and examined false positives to determine reasons for incorrect identification and true positives to determine clinical consequences and potential risk factors of PRF.

RESULTS

Seventy-five cases were true positive (PPV 67%; 95% CI, 57-76%); 13% were identified by a diagnosis code, 53% by a procedure code, 33% by both. Of false positives, 19% represented coding errors, 76% represented nonelective admissions. Of true positives, 28% of patients died, 56% had an American Society of Anesthesiologists level higher than II. Of associated index procedures, 53% were abdominal/pelvic, and 56% lasted >3 hours.

CONCLUSIONS

Based on our and University HealthSystem Consortium's findings, PRF should continue to be used as a screen for potential patient-safety events. Its PPV could be substantially improved in the Veterans Health Administration through introduction of an admission status code. Many PRF-identified cases appeared to be at high risk, based on patient and procedure-related factors. The degree to which such cases are truly preventable events requires additional assessment.

Risk factor model to predict venous thromboembolism in hospitalized medical patients

BACKGROUND

The Joint Commission requires that all medical inpatients be assessed for venous thromboembolism (VTE) risk, but available risk stratification tools have never been validated.

METHODS

We conducted a retrospective cohort study of patients age ≥18 years, admitted to 374 US hospitals in 2004-2005, with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection, and length of stay ≥3 days. Subjects were randomly assigned (80/20) to a derivation or validation set. We then assessed VTE (International Classification of Diseases, Ninth Revision [ICD-9] code plus diagnostic test plus treatment), patient demographics, 21 potential risk factors, and other comorbidities. We created a VTE risk stratification tool using multivariable regression modeling and applied it to the validation sample.

RESULTS

Of 242,738 patients, 612 (0.25%) patients fulfilled our criteria for VTE during hospitalization, and an additional 440 (0.18%) were readmitted for VTE within 30 days (overall incidence of 0.43%). In the multivariable model, age, sex, and 10 additional risk factors were associated with VTE. The strongest risk factors were inherited thrombophilia (OR 4.00), length of stay ≥6 days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. In the validation set, the model had a c-statistic of 0.75 (95% CI 0.71, 0.78). Deciles of predicted risk ranged from 0.11% to 1.46% with observed risk over the same deciles from 0.17% to 1.81%.

CONCLUSIONS

The risk of symptomatic VTE in general medical patients is low. A risk factor model can identify those at sufficient risk to warrant pharmacologic prophylaxis.

Socioeconomic disparities in ectopic pregnancy: predictors of adverse outcomes from Illinois hospital-based care, 2000-2006

This study aimed to identify the incidence of adverse outcomes from ectopic pregnancy hospital care in Illinois (2000-2006), and assess patient, neighborhood, hospital and time factors associated with these outcomes. Discharge data from Illinois hospitals were retrospectively analyzed and ectopic pregnancies were identified using DRG and ICD-9 diagnosis codes. The primary outcome was any complication identified by ICD-9 procedure codes. Secondary outcomes were length of stay and discharge status. Residential zip codes were linked to 2000 U.S. Census data to identify patients' neighborhood demographics. Logistic regression was used to identify risk factors for adverse outcomes. Independent variables were insurance status, age, co-morbidities, neighborhood demographics, hospital type, hospital ectopic pregnancy service volume, and year of discharge. Of 13,007 ectopic pregnancy hospitalizations, 7.4% involved at least one complication identified by procedure codes. Hospitalizations covered by Medicare (for women with chronic disabilities) were more likely than those with other source or without insurance to result in surgical sterilization (OR 4.7, P = 0.012). Hospitalization longer than 2 days was more likely with Medicaid (OR 1.46, P < 0.0005) or no insurance (OR 1.35, P < 0.0005) versus other payers, and among church-operated versus secular hospitals (OR 1.21, P < 0.0005). Compared to public hospitals, private hospitals had lower rates of complications (OR 0.39, P < 0.0005) and of hospitalization longer than 2 days (OR 0.57, P < 0.0005). With time, hospitalizations became shorter (OR 0.53, P < 0.0005) and complication rates higher (OR 1.33, P = 0.024). Ectopic pregnancy patients with Medicaid, Medicare or no insurance, and those admitted to public or religious hospitals, were more likely to experience adverse outcomes.

Population-level comparative effectiveness of laparoscopic versus open radical nephrectomy for patients with kidney cancer

BACKGROUND

Because there is limited population-based evidence supporting the comparative effectiveness of laparoscopic radical nephrectomy (LRN) after its widespread adoption, we compared trends in hospital-based outcomes among patients with kidney cancer treated with LRN or open radical nephrectomy (ORN).

METHODS

Using linked SEER-Medicare data, the authors identified patients with kidney cancer who were treated with LRN or ORN from 2000 through 2005. The authors measured 4 primary outcomes: intensive care unit (ICU) admission, prolonged length of stay, 30-day hospital readmission, and in-hospital mortality. The authors then estimated the association between surgical approach and each outcome, adjusting for patient demographics, tumor characteristics, and year of surgery.

RESULTS

The authors identified 2108 (26%) and 5895 (74%) patients treated with LRN and ORN, respectively. Patients treated with LRN were more likely to be white, female, of higher socioeconomic position, and to have tumor sizes of ≤4 cm (all P < .05). The adjusted probability of ICU admission and prolonged length of stay was 41% and 46% lower, respectively, for patients undergoing LRN (P < .001). Although uncommon for both groups, the adjusted probability of in-hospital mortality was 51% higher (2.3% vs 1.5%, P = .04) for patients treated with a laparoscopic approach.

CONCLUSIONS

At a population level, patients treated with LRN have a lower likelihood of ICU admission and prolonged length of stay, supporting the convalescence benefits of laparoscopy. In-hospital mortality, however, was higher among patients treated with LRN. The latter finding suggests a potentially unanticipated consequence of this technique and highlights the need for long-term monitoring during and after the widespread adoption of new surgical technologies.

Surgical complications are associated with omission of chemotherapy for stage III colorectal cancer

PURPOSE

Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer.

METHODS

We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied.

RESULTS

We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001).

CONCLUSIONS

Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

Complications rates of non-oncologic urologic procedures in population-based data: a comparison to published series

PURPOSE

Published single institutional case series are often performed by one or more surgeons with considerable expertise in specific procedures. The reported incidence of complications in these series may not accurately reflect community-based practice. We sought to compare complication and mortality rates following urologic procedures derived from population-based data to those of published single-institutional case series.

MATERIALS AND METHODS

In-hospital mortality and complications of common urologic procedures (percutaneous nephrostomy, ureteropelvic junction obstruction repair, ureteroneocystostomy, urethral repair, artificial urethral sphincter implantation, urethral suspension, transurethral resection of the prostate, and penile prosthesis implantation) reported in the U.S.'s National Inpatient Sample of the Healthcare Cost and Utilization Project were identified. Rates were then compared to those of published single-institution series using statistical analysis.

RESULTS

For 7 of the 8 procedures examined, there was no significant difference in rates of complication or mortality between published studies and our population-based data. However, for percutaneous nephrostomy, two published single-center series had significantly lower mortality rates (p < 0.001). The overall rate of complications in the population-based data was higher than published single or select multi-institutional data for percutaneous nephrostomy performed for urinary obstruction (p < 0.001).

CONCLUSIONS

If one assumes that administrative data does not suffer from under reporting of complications then for some common urological procedures, complication rates between population-based data and published case series seem comparable. Endorsement of mandatory collection of clinical outcomes is likely the best way to appropriately counsel patients about the risks of these common urologic procedures.

Impact of surgical experience on in-hospital complication rates in patients undergoing minimally invasive prostatectomy: a population-based study

BACKGROUND

The relationship between provider volume and complication and transfusion rates in patients undergoing minimally invasive prostatectomy (MIRP) for prostate cancer has not been assessed. Temporal trends in MIRP annual surgical caseload (AC), impact of MIRP surgical experience (SE), and in-hospital complication and transfusion rates were evaluated.

METHODS

Between 2002 and 2008, 2,666 patients in Florida underwent MIRP. Surgical experience was defined as the number of procedures performed from the beginning of the study until each individual MIRP. Multivariable logistic regression models using generalized estimating equations assessed the relationship between SE and in-hospital complication and transfusion rates.

RESULTS

Overall AC and SE ranged from 1-171 and 1-500, respectively. Between 2002 and 2005, 94-100% of surgeons were considered as low AC tertile (≤15 MIRP) vs. 76-82% between 2006 and 2008. For the same time periods, low AC tertile surgeons performed 46-100 and 27-32% of all MIRPs respectively. Multivariable logistic regression models revealed 51 and 68% lower complication rates in patients operated on by surgeons of intermediate (17-76 MIRPs) and high SE (≥77 MIRPs) relative to surgeons of low SE (≤16 MIRPs). Similarly, transfusion rates were 80 and 83% lower for the same groups.

CONCLUSIONS

Our study is the first to indicate that high SE reduces MIRP complication and transfusion rates. Despite this observation, even in the most contemporary study year, most MIRP surgeons (82%) were in the low AC tertile and contributed to as many as 32% of all MIRPs. These findings should be considered at informed consent.

Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients?

The objectives of this study were to compare the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline-approved VTE prophylactic therapies (warfarin, low-molecular-weight heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). We analyzed clinical and administrative data from 93,840 patients who underwent primary TKA at 307 US hospitals over a 24-month period. Fifty-one thousand nine hundred twenty-three (55%) patients received warfarin, 37,198 (40%) received injectable agents, and 4719 (5%) received aspirin. After adjustment for patient and hospital factors, patients who received aspirin VTE prophylaxis (VTEP) had lower odds for thromboembolism compared to warfarin patients but with similar odds compared with injectable VTEP; there were no differences in risk of bleeding, infection, or mortality after adjustment. Our results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective VTEP for certain TKA patients.

Aggressive treatment style and surgical outcomes

OBJECTIVE

Aggressive treatment style, as defined by the Dartmouth Atlas of Health Care, has been implicated as an important factor contributing to excessively high medical expenditures. We aimed to determine the association between aggressive treatment style and surgical outcomes.

DATA SOURCES/STUDY SETTING

Medicare admissions to 3,065 hospitals for general, orthopedic, and vascular surgery between 2000 and 2005 (N = 4,558,215 unique patients).

STUDY DESIGN

A retrospective cohort analysis.

RESULTS

For elderly surgical patients, aggressive treatment style was not associated with significantly increased complications, but it was associated with significantly reduced odds of mortality and failure-to-rescue. The odds ratio for complications in hospitals at the 75th percentile of aggressive treatment style compared with those at the 25th percentile (a U.S.$10,000 difference) was 1.01 (1.00-1.02), p<.066; whereas the odds of mortality was 0.94 (0.93-0.95), p<.0001; and for failure-to-rescue it was 0.93 (0.92-0.94), p<.0001. Analyses that used alternative measures of aggressiveness--hospital days and ICU days--yielded similar results, as did analyses using only low-variation procedures.

CONCLUSIONS

Attempting to reduce aggressive care that is not cost effective is a laudable goal, but policy makers should be aware that there may be improved outcomes associated with patients undergoing surgery in hospitals with a more aggressive treatment style.

The effect of minimally invasive and open radical prostatectomy surgeon volume

OBJECTIVE

To determine the effect of minimally invasive radical prostatectomy (MIRP) surgeon volume on outcomes, and correlate with those of open radical prostatectomy retropubic (ORP).

METHODS AND MATERIALS

Observational population-based study of 8,831 men undergoing MIRP and ORP by 1,457 low, medium, and high volume surgeons from SEER-Medicare linked data from 2003 to 2007. After stratifying by surgeon ORP and MIRP volume, the following outcomes were studied: length of stay, transfusions, post-operative 30-day and anastomotic stricture complications, and use of additional cancer therapies.

RESULTS

Men undergoing MIRP with high and medium vs. low volume surgeons were less likely to require additional cancer therapies (4.5% and 4.7% vs. 7%, P = 0.020). Similarly, men undergoing ORP with high vs. medium and low volume surgeons were less likely to require additional cancer therapies (5.7% vs. 6.8% and 7.1%, P = 0.044). Men undergoing ORP with high vs. medium and low volume surgeons experienced shorter lengths of stay (2.9 vs. 3.3 and 3.6 days, P < 0.001), and fewer transfusions (15.4% vs. 21.3% and 22.7%, P = 0.017), 30-day complications (18.4% vs. 25.6% and 25.7%, P < 0.001), and anastomotic strictures (10.1% vs. 15.6% and 16.3%, P = 0.003). However, MIRP surgeon volume did not affect these outcomes.

CONCLUSIONS

Men undergoing MIRP or ORP with high volume surgeons were less likely to require additional cancer therapies. Additionally, patients of high volume ORP surgeons were more likely to experience shorter hospital stays, fewer transfusions, 30-day complications, and anastomotic strictures, while MIRP surgeon volume did not affect these peri-operative outcomes.

Care pathways and patient safety: key concepts, patient outcomes and related interventions

Although care pathways often target efficiency of care through mapping and standardizing care processes, care can also be improved by reducing patient safety events, such as complications. In this paper, the authors review key concepts and literature relevant to parallels between patient safety and pathway interventions, as well as patient safety issues that should be considered in pathway development and implementation. Both care pathways and patient safety interventions are more likely to be effective when based on a theoretical framework related to human or systems factors or behaviour. Care pathways can target patient safety outcomes, but can also produce new hazards, through applying standards too broadly, reducing adaptability to complex situations or changing care processes in unforeseen ways. Both pathways and safety interventions must also be efficient and consider the opportunity costs of the time needed for providers to implement the intervention. Further research should explore how best to standardize care when needed, while evaluating how best to prevent and monitor hazards, allow for innovation and adaptability to customize care when appropriate, and continue to develop new methods for improving quality.

The natural language of the surgeon's clinical note in outcomes assessment: a qualitative analysis of the medical record

BACKGROUND

Physician-generated clinical notes are the central document in recording the clinical decision-making and outcome of care. This is particularly true in an environment where outcomes assessment is becoming increasingly important. The hypothesis of this study is that these notes are inadequate to assess patient-centered outcomes and determine surgeons' core competencies.

METHODS

We preformed a retrospective review of postoperative clinical notes of general surgery patients for a 1-month period. Information from these notes underwent qualitative analysis using the reductionist thematic approach for patient-centered and physician-centered outcomes. Outcomes included 2 physician-centered items (physical examination and objective tests) and 3 patient-centered items (postoperative complications, functional status, and satisfaction). The presence or absence of each item in the clinical note was recorded.

RESULTS

Six hundred eighty-one patients of 18 general surgeons were included. Among the surgeons, 28% failed to document symptomatic change in even 1 patient; similarly, 67% failed to document functional change, and 50% failed to document satisfaction. Among all 681 clinical notes only 7% of records mentioned symptomatic change, 1% functional change, 87% physical examination, 26% objective tests, and 3% patient satisfaction. These results were not affected by procedure type or number of patients seen.

CONCLUSIONS

In general surgery practice, the surgeon's clinical note is a poor measure of physician-centered or patient-centered outcomes, implying that an audit of clinical notes would be an inaccurate method to assess patient outcomes. This has implications for issues surrounding maintenance of certification.

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

BACKGROUND

Patient Safety Indicator (PSI) 11, or postoperative respiratory failure, was developed by the US Agency for Healthcare Research and Quality to detect incident cases of respiratory failure after elective operations through use of ICD-9-CM diagnosis and procedure codes. We sought to determine the positive predictive value (PPV) of this indicator.

STUDY DESIGN

We conducted a retrospective cross-sectional study, sampling consecutive cases that met PSI 11 criteria from 18 geographically diverse academic medical centers on or before June 30, 2007. Trained abstractors from each center reviewed medical records using a standard instrument. We assessed the PPV of the indicator (with 95% CI adjusted for clustering within centers) and conducted descriptive analyses of the cases.

RESULTS

Of 609 cases that met PSI 11 criteria, 551 (90.5%; 95% CI, 86.5-94.4%) satisfied the technical criteria of the indicator and 507 (83.2%; 95% CI, 77.2-89.3%) represented true cases of postoperative respiratory failure from a clinical standpoint. The most frequent reasons for being falsely positive were nonelective hospitalization, prolonged intubation for airway protection, and insufficient evidence to support a diagnosis of acute respiratory failure. Fifty percent of true-positive cases involved substantial baseline comorbidities, and 23% resulted in death.

CONCLUSIONS

Although PSI 11 predicts true postoperative respiratory failure with relatively high frequency, the indicator does not limit detection to preventable cases. The PPV of PSI 11 might be increased by excluding cases with a principal diagnosis suggestive of a nonelective hospitalization and those with head or neck procedures. Removing the diagnosis code criterion from the indicator might also increase PPV, but would decrease the number of true positive cases detected by 20%.

Predictors of major complications after laparoscopic cholecystectomy: surgeon, hospital, or patient?

BACKGROUND

Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists about whether more common procedures should be performed at high-volume centers. Using mortality alone to assess routine operations is hampered by relatively low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications after laparoscopic cholecystectomy (LC).

STUDY DESIGN

Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed. Univariate and multivariable analyses were performed and independent risk factors of complications were identified.

RESULTS

A total of 1,102,071 weighted patient discharges were identified, with a complication rate of 6.8%. Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates (p < 0.0001). Higher surgeon volume (>or=36/year versus <12/year) and higher hospital volume (>or=225/year versus <or=120/year) were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively; p < 0.0001). Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years; adjusted odds ratio [AOR] = 2.16; 95% CI, 2.01-2.32), male gender (AOR = 1.14; 95% CI, 1.10-1.19), and comorbidities (Charlson Comorbidity Score 2 versus 0; AOR = 2.49; 95% CI, 2.34-2.65) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications.

CONCLUSIONS

Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.

Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults

CONTEXT

In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure.

OBJECTIVE

To examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n = 32,152 in the first 11 months of 2007) were grouped into 3 gradations of invasiveness: decompression alone, simple fusion (1 or 2 disk levels, single surgical approach), or complex fusion (more than 2 disk levels or combined anterior and posterior approach).

MAIN OUTCOME MEASURES

Rates of the 3 types of surgery, major complications, postoperative mortality, and resource use.

RESULTS

Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.

CONCLUSIONS

Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.

Trends in adrenalectomy: a recent national review

BACKGROUND

Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality.

METHODS

The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated.

RESULTS

Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82).

CONCLUSION

Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.

Measuring quality for public reporting of health provider quality: making it meaningful to patients

Public quality reports of hospitals, health plans, and physicians are being used to promote efficiency and quality in the health care system. Shrinkage estimators have been proposed as superior measures of quality to be used in these reports because they offer more conservative and stable quality ranking of providers than traditional, nonshrinkage estimators. Adopting the perspective of a patient faced with choosing a local provider on the basis of publicly provided information, we examine the advantages and disadvantages of shrinkage and nonshrinkage estimators and contrast the information made available by them. We demonstrate that 2 properties of shrinkage estimators make them less useful than nonshrinkage estimators for patients making choices in their area of residence.

Predicting major complications after laparoscopic cholecystectomy: a simple risk score

INTRODUCTION

Reported morbidity varies widely for laparoscopic cholecystectomy (LC). A reliable method to determine complication risk may be useful to optimize care. We developed an integer-based risk score to determine the likelihood of major complications following LC.

METHODS

Using the Nationwide Inpatient Sample 1998-2006, patient discharges for LC were identified. Using previously validated methods, major complications were assessed. Preoperative covariates including patient demographics, disease characteristics, and hospital factors were used in logistic regression/bootstrap analyses to generate an integer score predicting postoperative complication rates. A randomly selected 80% was used to create the risk score, with validation in the remaining 20%.

RESULTS

Patient discharges (561,923) were identified with an overall complication rate of 6.5%. Predictive characteristics included: age, sex, Charlson comorbidity score, biliary tract inflammation, hospital teaching status, and admission type. Integer values were assigned and used to calculate an additive score. Three groups stratifying risk were assembled, with a fourfold gradient for complications ranging from 3.2% to 13.5%. The score discriminated well in both derivation and validation sets (c-statistic of 0.7).

CONCLUSION

An integer-based risk score can be used to predict complications following LC and may assist in preoperative risk stratification and patient counseling.