301
|
Tseng JF, Pisters PWT, Lee JE, Wang H, Gomez HF, Sun CC, Evans DB. The learning curve in pancreatic surgery. Surgery 2007; 141:456-63. [PMID: 17383522 DOI: 10.1016/j.surg.2006.09.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 09/13/2006] [Accepted: 09/24/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic operation is technically complex. We hypothesized that a learning curve existed for pancreaticoduodenectomy even for surgeons who had completed their training. METHODS During 1990 to 2004, we studied 650 consecutive patients who underwent pancreaticoduodenectomy by 3 surgeons who began their attending careers at 1 center. Operative time, estimated blood loss (EBL), length of hospital stay (LOS), and the status of resection margins (for pancreatic adenocarcinoma) were analyzed. The chi(2), independent t test and Mann-Whitney U test were used to evaluate differences in categoric, normally distributed continuous, and non-normally distributed continuous variables, respectively. Using serial groups of 30 cases, median operative time, EBL, and LOS were calculated and the trend over time modeled using third-order polynomial equations. Trends in retroperitoneal margin positivity (R0/R1) were assessed. RESULTS From the first 60 cases per surgeon to the second 60 cases per surgeon, the median EBL dropped (1100 vs 725 mL, P < .001), operative time decreased (589 vs 513 minutes, P < .001), and LOS decreased (15 vs 13 days, P = .004). The proportion of microscopically positive or suspicious margins also decreased from the surgeons' first 60 cases each to the second 60 cases (30% vs 8%, P < .001). Extended analysis of a single surgeon's cases suggested that additional experience provided further incremental improvement (P < .001). CONCLUSIONS Pancreaticoduodenectomy has an inherent learning curve. After 60 cases, surgeons achieved significantly decreased EBL, operative time, and LOS, and carried out more margin-negative resections. Improvement in measured outcomes continues during the operative career.
Collapse
Affiliation(s)
- Jennifer F Tseng
- Department of Surgery and the UMass Memorial Cancer Center, University of Massachusetts Medical School, Worcester, Mass, USA.
| | | | | | | | | | | | | |
Collapse
|
302
|
Votruba ME, Cebul RD. Redirecting patients to improve stroke outcomes: implications of a volume-based approach in one urban market. Med Care 2007; 44:1129-36. [PMID: 17122718 DOI: 10.1097/01.mlr.0000237424.15716.47] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The designation of primary stroke centers may result in patients being redirected from their usual source of care, although there is little evidence that these centers would result in better outcomes or lower costs. An alternative approach could direct patients to hospitals treating greater volumes of stroke patients. OBJECTIVES We sought to estimate the effect of hospital stroke volume on patient mortality and costs in a regional hospital market and to analyze the implications of hypothetical volume-based referral policies in that market, including the effects of patient-hospital distance. METHODS Using a retrospective cohort, we studied 12,150 Medicare patients admitted for acute stroke to 1 of 29 hospitals in Greater Cleveland during a 7-year period. The primary outcome was risk-adjusted 30-day mortality. Secondary outcomes included log hospital costs and discharge destination. The primary measure of volume was average annual number of stroke patients; patient distance to the nearest hospital was approximated using patient zip code and hospital address data. RESULTS Overall 30-day mortality was 14.9%. For each 100-patient increase in hospitals' annual stroke volume, risk-adjusted mortality declined 0.9 percentage points (odds ratio = 0.90; 95% confidence interval = 0.82-0.98; P < 0.02) with no significant difference in hospital costs. For each 1-mile increase in patient distance to nearest hospital, mortality increased 0.6 percentage points (odds ratio = 1.07; 95% confidence interval = 1.03-1.11; P < 0.01). Only 3 of 29 hospitals (10.3%) exceeded the highest plausible threshold (250 strokes/year), redirecting 81.4% of patients for a net reduction in mortality of 0.4%; lower thresholds would redirect fewer patients but have negligible effects on mortality. CONCLUSIONS Our findings fail to support redirecting acute stroke patients based on hospital stroke volume.
Collapse
Affiliation(s)
- Mark E Votruba
- Department of Economics, Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio, USA
| | | |
Collapse
|
303
|
Abstract
OBJECTIVE To demonstrate that total joint replacement surgery can be safely and effectively performed in rural hospitals with acceptable outcomes. DESIGN Case series. SETTING A rural district hospital. PARTICIPANTS PARTICIPANTS were 64 patients, 30 men and 34 women, who underwent total knee replacements (TKR); and 63 patients, 41 men and 22 women, who had total hip replacements (THR). MAIN OUTCOME MEASURES Level of patient satisfaction following total joint replacement surgery, obtained by patient interview. Incidence of postoperative joint specific complications, for example infection, THR dislocation and manipulation under anaesthetic (MUA) of a TKR. RESULTS None of the TKR or THR patients developed a deep wound infection. In this study 8.8% TKR patients had an MUA but all during a period of limited physiotherapy services; 5.8% THR patients suffered a dislocated prosthesis. Following TKR 95.3% patients reported to be 'happy' with the outcome of their surgery. Of the THR patients 97.0% declared they were 'happy' with their surgical outcome. CONCLUSIONS There was a high level of patient satisfaction, low infection rate, acceptable levels of MUA for TKR and dislocation for THR following total joint replacement in our rural district hospital. The surgeons performed a medium volume of total joint replacements and an appropriate multidisciplinary team was in place. In such settings joint replacement surgery can be safely and successfully performed in rural centres to the benefit of rural patients, surgeons and GPs.
Collapse
MESH Headings
- Aged
- Arthritis, Rheumatoid/surgery
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/psychology
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/psychology
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Female
- Femur Head Necrosis/surgery
- Follow-Up Studies
- Health Services Research
- Hospitals, District
- Hospitals, Rural
- Humans
- Male
- Manipulation, Orthopedic/statistics & numerical data
- New South Wales/epidemiology
- Osteoarthritis/surgery
- Outcome Assessment, Health Care
- Patient Care Team
- Patient Satisfaction
- Prosthesis Failure
- Prosthesis-Related Infections/epidemiology
- Prosthesis-Related Infections/etiology
- Quality Indicators, Health Care
- Registries
- Safety
- Surveys and Questionnaires
Collapse
|
304
|
Abstract
Multiple studies support the intuitive association between higher provider procedure volume and better clinical outcomes. Health care purchasers and payers have been seeking ways to direct patients to high-volume providers to improve the quality of care received and to avoid costs associated with higher surgical morbidity. Volume-based referral has faced resistance from providers who are concerned that the use of volume instead of more direct measures of surgical quality will result in unfair discrimination. On close examination, volume-based referral policies also appear to be more congruent with payers’ interests than the interests of individual patients and providers. Furthermore, a policy of volume-based referral does not address surgical quality directly, is applicable to only a very small segment of surgical care, and is logistically problematic. However, in the absence of viable alternative measures of surgical quality, imperfect proxies such as volume will likely continue to be a significant part of the national dialogue surrounding surgical quality.
Collapse
Affiliation(s)
- Samuel R.G. Finlayson
- From the Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire and the Veteran's Administration Outcomes Group, White River Junction, Vermont
| |
Collapse
|
305
|
Stewart GD, Long G, Tulloh BR. Surgical service centralisation in Australia versus choice and quality of life for rural patients. Med J Aust 2006; 185:162-3. [PMID: 16893360 DOI: 10.5694/j.1326-5377.2006.tb00507.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 05/07/2006] [Indexed: 11/17/2022]
Abstract
High patient volume for both hospitals and surgeons is an important determinant of operative mortality and outcome for complex and infrequently performed operations. The 13% of Australia's population who live in rural and remote areas often choose to have surgery close to home and support networks despite the potentially higher operative mortality and morbidity. Rural patients should be able to make an informed choice about having their surgery locally. Rural and metropolitan surgeons should discuss and reach mutual agreement on where each patient is best treated. A balance must be struck between quality of services that can be provided locally and geographic convenience.
Collapse
Affiliation(s)
- Grant D Stewart
- Department of Clinical and Surgical Services (Surgery), Edinburgh University, Edinburgh, United Kingdom.
| | | | | |
Collapse
|
306
|
Losina E, Kessler CL, Wright EA, Creel AH, Barrett JA, Fossel AH, Katz JN. Geographic diversity of low-volume hospitals in total knee replacement: implications for regionalization policies. Med Care 2006; 44:637-45. [PMID: 16799358 DOI: 10.1097/01.mlr.0000223457.92978.34] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Centers performing low volumes of total knee replacements (TKR) have worse outcomes of TKR than higher volume centers. Regionalization policies that shift patients to higher volume centers are being considered as a means of improving TKR outcomes. We sought to describe geographic diversity in the distribution of low-volume centers and examine state level characteristics associated with states that have a higher proportion of low-volume centers and/or a higher proportion of TKRs performed in low-volume centers. METHODS We used U.S. Census data and geocoded Medicare claims to ascertain state-level demographic factors, procedure volume, and TKR rates and to conduct our state level analysis. We defined 2 outcomes: 1) proportion of all hospitals with a low annual TKR volume (<26 per year in the Medicare population); and 2) proportion of all TKRs in the Medicare population performed in low-volume centers. We examined linear associations among the 2 outcomes and state factors, and used multivariate regression to identify factors associated independently with these outcomes. RESULTS Half of hospitals performing TKR in the Medicare population were low-volume centers, accounting for 13% of TKRs. Multivariate analysis revealed lower TKR rates, higher proportion of rural areas and larger state area were associated with a higher proportion of low-volume hospitals in a state. Lower proportion of elderly residents, higher population density and higher proportion of rural areas predicted a higher proportion of TKRs performed in low-volume centers. CONCLUSIONS The distribution of low-volume hospitals among U.S. states varies substantially. Regionalization of TKR may require different strategies in states with small and large numbers of low-volume centers.
Collapse
Affiliation(s)
- Elena Losina
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA.
| | | | | | | | | | | | | |
Collapse
|
307
|
Birkmeyer JD, Sun Y, Goldfaden A, Birkmeyer NJO, Stukel TA. Volume and process of care in high-risk cancer surgery. Cancer 2006; 106:2476-81. [PMID: 16634089 DOI: 10.1002/cncr.21888] [Citation(s) in RCA: 176] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although relations between procedure volume and operative mortality are well established for high-risk cancer operations, differences in clinical practice between high-volume and low-volume centers are not well understood. The current study was conducted to examine relations between hospital volume, process of care, and operative mortality in cancer surgery. METHODS Using the Medicare claims database (2000-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer (n=71,558). Preoperative, intraoperative, and postoperative processes of care potentially related to operative mortality were identified from inpatient, outpatient, and physician claims files using appropriate International Classification of Diseases--Clinical Modification (ICD-9) and Current Procedural Terminology (CPT) codes. We then assessed variation in the use of each process according to hospital volume, adjusting for patient characteristics and procedure type. Study Participants were US Medicare patients. The main outcome measure was specific processes of care. RESULTS Relative to those at low-volume centers (lowest 20th by volume), patients at high-volume hospitals (highest 20th) were significantly more likely to undergo stress tests (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.21-1.87), but not other preoperative imaging tests. They were more likely to see medical or radiation oncologists (OR: 1.37, 95% CI: 1.16-1.62), but not other specialists, preoperatively. Although blood transfusions and use of epidural pain management did not vary significantly by volume, patients at high-volume hospitals had significantly longer operations and were more likely to receive perioperative invasive monitoring (OR: 2.56, 95% CI: 1.82-3.60). Differences in measurable processes of care did not explain volume-related differences in operative mortality to any significant degree. CONCLUSIONS Although high-volume and low-volume hospitals differ with regard to many aspects of perioperative care, mechanisms underlying volume-outcome relations in high-risk cancer surgery remain to be identified.
Collapse
Affiliation(s)
- John D Birkmeyer
- Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE), Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
| | | | | | | | | |
Collapse
|
308
|
Konety BR, Allareddy V, Modak S, Smith B. Mortality After Major Surgery for Urologic Cancers in Specialized Urology Hospitals: Are They Any Better? J Clin Oncol 2006; 24:2006-12. [PMID: 16648501 DOI: 10.1200/jco.2005.04.2622] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Specialty-specific hospitals and hospitals with a high volume of complex procedures have been shown to have better outcomes. We sought to determine whether a high volume of unrelated complex procedures or procedures in the same specialty area (urology) could translate into better outcomes after major urologic cancer surgery. Methods We performed a cross-sectional analysis of administrative discharge abstract data from the Nationwide Inpatient Sample of the Health Care Utilization Project for years 1998 to 2002. Comparison of outcome after three major urologic cancer–related surgical procedures (radical cystectomy [RC], radical nephrectomy [RN], and radical prostatectomy [RP]) at hospitals by procedure-specific volume, specialized urology status, and Leapfrog criteria was obtained to determine in-hospital mortality after the procedure. All patients in the database with a diagnosis of bladder, kidney, or prostate cancer being admitted for RC, RN, or RP between 1998 and 2002 were included. Results Neither specialized urology status nor meeting Leapfrog volume criteria for unrelated procedures was associated with lower odds of in-hospital mortality after any of the procedures examined. High-volume hospitals (for RC and RP) and moderate-volume hospitals (for RP) were associated with lower odds of mortality. None of the examined hospital volume–related factors was associated with lower odds of mortality after RN. Conclusion In-hospital mortality after two of three major urologic cancer procedures is affected only by procedure-specific volumes. Generalized process measures existing in hospitals performing a high volume of general urologic procedures or unrelated complex procedures may be less important determinants of procedure-specific outcomes in patients.
Collapse
Affiliation(s)
- Badrinath R Konety
- Department of Urology, Carver College of Medicine and College of Public Health, University of Iowa, Iowa City, IA, USA.
| | | | | | | |
Collapse
|
309
|
Feudtner C, Silveira MJ, Shabbout M, Hoskins RE. Distance from home when death occurs: a population-based study of Washington State, 1989-2002. Pediatrics 2006; 117:e932-9. [PMID: 16651296 DOI: 10.1542/peds.2005-2078] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE For patients who die in hospitals, the regionalization of tertiary health care services may be increasing the home-to-hospital distance, particularly for younger patients whose care is especially regionalized and for whom access to and use of home hospice services remains limited. The objective of this study was to test the hypotheses that the distance from home at the time of death in a hospital has increased over time and is inversely related to the age of the dying patient. METHODS A population-based case series was conducted in Washington State of all deaths of state residents from 1989 to 2002. The main outcome measure was driving distance between home residence and location at the time of death. RESULTS The overall mean distance from home to the hospital where death occurred has increased by 1% annually. Children who died in hospitals were much farther from home than their adult counterparts: the mean distance was 37.4 km for neonates and 50.9 km for children who were aged 1 to 9 years, compared with 19.9 km for adults who were aged 60 to 79 years and 14.0 km for patients who were older than 79 years. Disparities of distance were even greater among patients who were at the 90th percentile for distance (85.6 km for neonates compared with 30.8 for patient who were older than 79 years). CONCLUSIONS The distance between home residence and the hospital where death occurs is greatest for children and has increased over time. Both of these findings have implications for the design of local and regional pediatric end-of-life supportive care services.
Collapse
Affiliation(s)
- Chris Feudtner
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
310
|
Callcut RA, Breslin TM. Shaping the future of surgery: the role of private regulation in determining quality standards. Ann Surg 2006; 243:304-12. [PMID: 16495692 PMCID: PMC1448933 DOI: 10.1097/01.sla.0000200854.34298.e3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To educate surgeons about the growth of the private regulatory movement and its potential implications for the practice of surgery. METHODS An in-depth analysis and literature review of one of the largest private regulatory groups, the Leapfrog Group, provides a model for understanding the impact of these groups on the practice of surgery. A detailed discussion of the history, mission, structure, and quality initiatives of Leapfrog is included. RESULTS Private regulatory groups are using quality standards as a method for controlling the rising cost of health care. Traditionally, little financial support, manpower, or incentives have existed for individual surgeons and hospitals to report and maintain their own outcomes data. However, as surgical outcomes have increasingly become the target of quality improvement initiatives, the need to measure performance is gaining importance. Surgical quality has been both a direct target of private regulation, as illustrated by the evidence-based hospital referral guidelines of Leapfrog, and an indirect target with initiatives like computerized physician order entry and ICU staffing guidelines. CONCLUSIONS Private regulation is rapidly reshaping the way we practice and teach surgery. It is almost a certainty that their power, popularity, financial support, and missions will all continue to expand. As surgeons, we must decide soon if we wish to be an active participant in shaping the movement or, rather, if we are going to let it shape us by remaining largely uninvolved.
Collapse
|
311
|
Judge A, Chard J, Learmonth I, Dieppe P. The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England. J Public Health (Oxf) 2006; 28:116-24. [PMID: 16597628 DOI: 10.1093/pubmed/fdl003] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Previous work from other countries has shown a significant inverse relationship between the number of some surgical procedures undertaken in a hospital and in an adverse outcomes. In the light of the changing nature of the provision of joint replacements in the United Kingdom, we have examined the effects of surgical volumes and the presence/absence of training centre status, on outcomes following total joint replacement (TJR) in England. METHODS Analysis of the Hospital Episode Statistics (HES) on all hip/knee joint replacements in English National Health Service (NHS) trusts between financial years 1997 and 2002. Exposures explored were the volume of hip/knee replacements per annum in an NHS trust, training centre status and whether the admission was routine or emergency. Four surrogate measures of adverse outcome were assessed: 30-day in-hospital mortality, length of stay in hospital, readmission within a year and surgical revision within 5 years. Age and sex were controlled for as potential confounders. RESULTS Data from a total of 281 360 hip replacements and 211 099 knee replacements were examined. HES data show that the numbers of TJRs performed in low volume trusts are small and decreasing. Adverse outcomes were also uncommon. Nevertheless, significant associations between adverse outcomes and low volume units, and better outcomes in training centres, were detected. For example, the odds ratio (OR) for in-hospital death within 30 days of hip replacement in trusts doing <50 hip/replacements per annum is 1.98 [95% confidence interval (95% CI) = 1.13-3.47] compared with trusts doing 251-500 operations/annum. Similarly, surgery in non-training centres is more likely to result in mortality than that in training centres (OR = 1.25, 95% CI = 1.05-1.48). The examination of surgical revision indicated adverse outcomes in higher volume units; this may be due to case-mix. CONCLUSION In England, there are fewer adverse events following TJR in high volume centres and in orthopaedic training centres. Standardization of procedures may account for this finding. The data have implications for private practice in the United Kingdom and for the current move to undertake TJRs in Independent Sector Treatment Centres.
Collapse
Affiliation(s)
- Andy Judge
- MRC Health Services Research Collaboration, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK
| | | | | | | |
Collapse
|
312
|
Berry JG, Cowley CG, Hoff CJ, Srivastava R. In-hospital mortality for children with hypoplastic left heart syndrome after stage I surgical palliation: teaching versus nonteaching hospitals. Pediatrics 2006; 117:1307-13. [PMID: 16585328 DOI: 10.1542/peds.2005-1544] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Teaching hospitals are perceived to provide a higher quality of care for the treatment of rare disease and complex patients. A substantial proportion of stage I palliation for hypoplastic left heart syndrome (HLHS) may be performed in nonteaching hospitals. This study compares the in-hospital mortality of stage I palliation between teaching and nonteaching hospitals. METHODS The authors conducted a retrospective cohort study using the Kids' Inpatient Database 1997 and 2000. Patients with HLHS undergoing stage I palliation were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. RESULTS Seven hundred fifty-four and 880 discharges of children with HLHS undergoing stage I palliation in 1997 and 2000, respectively, were identified. The in-hospital mortality for the study population was 28% in 1997 and 24% in 2000. Twenty percent of stage I palliation operations were performed in nonteaching hospitals in 1997. Two percent of operations were performed in nonteaching hospitals in 2000. In 1997 only, in-hospital mortality remained higher in nonteaching hospitals after controlling for stage I palliation hospital volume and condition-severity diagnoses. Low-volume hospitals performing stage I palliation were associated with increased in-hospital mortality in 1997 and 2000. CONCLUSIONS Patients with HLHS undergoing stage I palliation in nonteaching hospitals experienced increased in-hospital mortality in 1997. A significant reduction in the number of stage I palliation procedures performed in nonteaching hospitals occurred between 1997 and 2000. This centralization of stage I palliation into teaching hospitals, along with advances in postoperative medical and surgical care for these children, was associated with a decrease in mortality. Patients in low-volume hospitals performing stage I palliation continued to experience increased mortality in 2000.
Collapse
Affiliation(s)
- Jay G Berry
- Pediatric Health Services Research Fellowship Program, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | |
Collapse
|
313
|
Abstract
Public reporting of provider performance is becoming increasingly commonplace. In this chapter, we first review studies of prior public reports (or report cards) that show real but small impact on provider attempts to improve quality, on consumers' impressions of providers, and even on consumer selection of providers. Among other factors, two potential explanations for the low level of impact are that, in most early reports, the large majority of providers have been labeled "average" and consumers may have had difficulty understanding the statistical assessments. In response, some current report card producers are using or considering a variety of methods to increase the number of distinctions among providers and the ease of comprehension of the labels used. Therefore, we also consider the advantages and disadvantages of several novel approaches to analyzing and reporting provider performance.
Collapse
Affiliation(s)
- David L Robinowitz
- Pediatric Pulmonary Medicine, Institute of Health Policy Studies, University of California, San Francisco, California 94143, USA.
| | | |
Collapse
|
314
|
Abstract
The current literature demonstrates that both hospital volume and surgeon volume are inversely related to operative mortality for esophageal resection. Given the heterogeneity of the volume-outcome literature, it is difficult to identify minimum volume thresholds at which satisfactory performance is achieved. Both volume-based hospital referral and process improvement provide compelling and sometimes competing strategies for translating evidence about volume-outcome relationships into policy. Each approach has significant limitations that preclude uniform implementation nationwide but nonetheless should be a focus for continued investigation and application, with the goal of providing uniform and high-quality care after esophagectomy.
Collapse
Affiliation(s)
- Andrew C Chang
- Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor 48109, USA.
| | | |
Collapse
|
315
|
van Heek NT, Kuhlmann KFD, Scholten RJ, de Castro SMM, Busch ORC, van Gulik TM, Obertop H, Gouma DJ. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 2006; 242:781-8, discussion 788-90. [PMID: 16327488 PMCID: PMC1409869 DOI: 10.1097/01.sla.0000188462.00249.36] [Citation(s) in RCA: 279] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate the best available evidence on volume-outcome effect of pancreatic surgery by a systematic review of the existing data and to determine the impact of the ongoing plea for centralization in The Netherlands. SUMMARY BACKGROUND DATA Centralization of pancreatic resection (PR) is still under debate. The reported impact of hospital volume on the mortality rate after PR varies. Since 1994, there has been a continuous plea for centralization of PR in The Netherlands, based on repetitive analysis of the volume-outcome effect. METHODS A systematic search for studies comparing hospital mortality rates after PR between high- and low-volume hospitals was used. Studies were reviewed independently for design features, inclusion and exclusion criteria, cutoff values for high and low volume, and outcome. Primary outcome measure was hospital or 30-day mortality. Data were obtained from the Dutch nationwide registry on the outcome of PR from 1994 to 2004. Hospitals were divided into 4 volume categories based on the number of PRs performed per year. Interventions and their effect on mortality rates and centralization were analyzed. RESULTS Twelve observational studies with a total of 19,688 patients were included. The studies were too heterogeneous to allow a meta-analysis; therefore, a qualitative analysis was performed. The relative risk of dying in a high-volume hospital compared with a low-volume hospital was between 0.07 and 0.76, and was inversely proportional to the volume cutoff values arbitrarily defined. In 5 evaluations within a decade, hospital mortality rates were between 13.8% and 16.5% in hospitals with less than 5 PRs per year, whereas hospital mortality rates were between 0% and 3.5% in hospitals with more than 24 PRs per year. Despite the repetitive plea for centralization, no effect was seen. During 2001, 2002, and 2003, 454 of 792 (57.3%) patients underwent surgery in hospitals with a volume of less than 10 PRs per year, compared with 280 of 428 (65.4%) patients between 1994 and 1996. CONCLUSIONS The data on hospital volume and mortality after PR are too heterogeneous to perform a meta-analysis, but a systematic review shows convincing evidence of an inverse relation between hospital volume and mortality and enforces the plea for centralization. The 10-year lasting plea for centralization among the surgical community did not result in a reduction of the mortality rate after PR or change in the referral pattern in The Netherlands.
Collapse
Affiliation(s)
- N Tjarda van Heek
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
316
|
Abstract
Commonly performed elective surgical procedures on the alimentary tract are carried out with low morbidity and low mortality in most hospitals in the United States. There are some procedures on the alimentary tract that are performed with a relatively low frequency and are associated with higher mortality. Volume is a surrogate marker associated with improved outcome, with relative differences being dependent on the complexity of the procedure and the frequency with which it is done. Both surgeon and institutional volume matters, but it seems that improved operative mortality can be reached with lower surgeon volume in high-volume institutions. It appears that volume can be substituted in part for by specialization and training, with improved outcomes based on specialist credentials and fellowship training.
Collapse
Affiliation(s)
- David J Bentrem
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | | |
Collapse
|
317
|
Nallamothu BK, Eagle KA, Ferraris VA, Sade RM. Should Coronary Artery Bypass Grafting Be Regionalized? Ann Thorac Surg 2005; 80:1572-81. [PMID: 16242420 DOI: 10.1016/j.athoracsur.2005.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 04/04/2005] [Accepted: 04/04/2005] [Indexed: 11/27/2022]
Affiliation(s)
- Brahmajee K Nallamothu
- Health Services Research & Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | | | | | | |
Collapse
|
318
|
Hollenbeck BK, Taub DA, Miller DC, Dunn RL, Montie JE, Wei JT. The regionalization of radical cystectomy to specific medical centers. J Urol 2005; 174:1385-9; discussion 1389. [PMID: 16145443 DOI: 10.1097/01.ju.0000173632.58991.a7] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Regionalization of high risk surgical procedures to larger teaching hospitals has been suggested as a means to improve the quality of care. We established a novel framework for characterizing regionalization, implemented it to determine the extent to which regionalization of radical cystectomy has occurred and delineated whether specific patient characteristics are associated with this phenomenon. MATERIALS AND METHODS We used the Nationwide Inpatient Sample to identify 22,088 patients who underwent radical cystectomy for bladder cancer from 1988 to 2000. Regionalization was assessed using 5 structural hospital measures, including teaching status, urban location, discharge volume, cystectomy volume and bed capacity. Adjusted models were developed to identify the significance of temporal trends and assess the association of demographic factors with structural qualities. RESULTS Compared with 1988 to 1990 subjects were more likely to undergo cystectomy at teaching hospitals (OR 1.8), high cystectomy volume hospitals (OR 1.2), high discharge volume hospitals (OR 1.7) and large bed capacity medical centers (OR 1.4) in 1998 to 2000. The concentration of cystectomy to urban medical centers during the study years was 90% to 92%. The proportion of subjects undergoing partial cystectomy decreased from 23.9% to 16.6% as regionalization occurred. Older subjects were less likely to be treated at these regionalized centers. CONCLUSIONS Without broad legislation from health care payers radical cystectomy has increasingly regionalized to specific medical centers. Despite this regionalization disparities in its use exist among specific, vulnerable patients. Addressing this may facilitate further concentration of this procedure.
Collapse
Affiliation(s)
- Brent K Hollenbeck
- Department of Urology, University of Michigan, Ann Arbor, Michigan 48109-0330, USA.
| | | | | | | | | | | |
Collapse
|
319
|
Abstract
OBJECTIVE To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions. DESIGN National telephone interview study. SETTING United States. PARTICIPANTS 510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier--abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate. RESULTS Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%). CONCLUSION Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians.
Collapse
Affiliation(s)
- Lisa M Schwartz
- VA Outcomes Group (111B), VA Medical Center, 215 N Main Street, White River Junction, VT 05009, USA
| | | | | |
Collapse
|
320
|
McGrath DR, Leong DC, Gibberd R, Armstrong B, Spigelman AD. Surgeon and hospital volume and the management of colorectal cancer patients in Australia. ANZ J Surg 2005; 75:901-10. [PMID: 16176237 DOI: 10.1111/j.1445-2197.2005.03543.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The evidence for a relationship between patient outcomes and clinician and hospital volume is increasing. The National Colorectal Cancer Care Survey was undertaken to determine the management patterns in Australia for individuals newly diagnosed with colorectal cancer in a 3 month period in the year 2000. METHODS All new cases of colorectal cancer registered at each Australian State Cancer Registry were entered into the survey. This generated a questionnaire that was sent to the treating surgeon. Chi-squared tests and logistic regression analyses were used to determine levels of statistical significance. RESULTS Of 2,383 surgical questionnaires generated, 2,015 (85%) were completed. The majority (58%) of surgeons treated one or two patients with colorectal cancer over the 3 months of the survey. There was variation across surgeon cohorts for preoperative measures including the use of deep vein thrombosis prophylaxis. Patients seen by low volume surgeons were most likely to be given a permanent stoma (P < 0.0001). Patients with rectal cancer who were operated on by high volume surgeons were significantly more likely to receive a colonic pouch (P < 0.0001). CONCLUSION This nationwide population-based survey of the treatment of colorectal cancer patients suggests that the delivery of care by surgeons (the majority) who treat patients with rectal cancer infrequently should be evaluated.
Collapse
Affiliation(s)
- Daniel R McGrath
- Surgical Science, Faculty of Health, University of Newcastle, Newcastle, New South Wales, Australia
| | | | | | | | | |
Collapse
|
321
|
Elting LS, Pettaway C, Bekele BN, Grossman HB, Cooksley C, Avritscher EBC, Saldin K, Dinney CPN. Correlation between annual volume of cystectomy, professional staffing, and outcomes: a statewide, population-based study. Cancer 2005; 104:975-84. [PMID: 16044400 DOI: 10.1002/cncr.21273] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The association between high procedure volume and lower perioperative mortality is well established among cancer patients who undergo cystectomy. However, to the authors' knowledge, the association between volume and perioperative complications has not been studied to date and hospital characteristics contributing to the volume-outcome correlation are unknown. In the current study, the authors studied these associations, emphasizing hospital factors that contribute to the volume-outcome correlation. METHODS Multiple-variable models of inpatient mortality and complications were developed among all 1302 bladder carcinoma patients who underwent cystectomy between January 1, 1999 and December 31, 2001 in all Texas hospitals. General estimating equations were used to adjust for clustering within the 133 hospitals. Data were obtained from hospital claims, the 2000 U.S. Census, and databases from the Center for Medicare and Medicaid Services and the American Hospital Association. RESULTS Complications were reported to occur in 12% of patients, 2.2% of whom died. Mortality was higher in low-volume hospitals compared with high-volume hospitals (3.1% vs. 0.7%; P < 0.001); mortality in moderate-volume hospitals was reported to be intermediate (2.9%). After adjustment for advanced age and comorbid conditions, treatment in high-volume hospitals was associated with lower risks of mortality (odds ratio [OR] = 0.35; P = 0.02) and complications (OR = 0.53; P = 0.01). Hospitals with a high registered nurse-to-patient ratio also had a lower mortality risk (OR = 0.43; P = 0.04). CONCLUSIONS Mortality after cystectomy was found to be significantly lower in high-volume hospitals, regardless of patient age. Referral to a hospital performing greater than 10 cystectomies annually is indicated for all patients. However, patients with poor access to a high-volume hospital may derive similar benefit from treatment at a hospital with a high-registered nurse-to-patient ratio. This finding requires further confirmation.
Collapse
Affiliation(s)
- Linda S Elting
- Section of Health Services Research, Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | | | | | | | | | |
Collapse
|
322
|
Abstract
PURPOSE Growing evidence suggests an association between higher hospital and surgeon volumes, and better outcomes after high risk surgical procedures. We reviewed the literature on volume and outcomes, specifically in urological cancer therapy. MATERIALS AND METHODS We searched the literature from 1966 to 2004 using MEDLINE with the keywords outcomes, urology, neoplasms, volume, hospital volume, surgeon volume, prostatectomy, cystectomy, nephrectomy, prostate cancer, bladder cancer, kidney cancer and testis cancer. Relevant articles were reviewed and results were compared for each urological cancer. RESULTS Several studies demonstrated that higher hospital volume is associated with better outcomes for all urological cancer surgeries. We found that long-term morbidity associated with radical prostatectomy is significantly associated with individual surgeon volume. There were variations in outcome even among high volume surgeons, suggesting that surgical technique can independently impact outcome. Hospitals with a high volume of cystectomies and nephrectomies had decreased overall mortality rates compared with low volume hospitals. Patients undergoing retroperitoneal lymph node dissection for metastatic germ cell tumor had statistically significantly improved survival when treated at larger oncology centers. CONCLUSIONS Evidence that high volume hospitals have better outcomes is increasing for urological cancer surgeries. Whether volume affects quality or better clinicians and services attract more patients can be debated. Centralizing health care will have major health policy implications, ie high volume hospitals may be overwhelmed and low volume hospitals may be at a disadvantage. An alternative would be to attempt to improve outcomes at low volume hospitals by identifying drivers of high quality care at high volume hospitals and transferring some of these characteristics.
Collapse
Affiliation(s)
- Fadi N Joudi
- University of Iowa Department of Urology, Iowa City, Iowa 52242, USA
| | | |
Collapse
|
323
|
David S, Durif-Bruckert C, Durif-Varembont JP, Lemery D, Masson G, Scharnitzky P, Claris O, Mamelle N. Perinatal care regionalization and acceptability by professionals in France. Rev Epidemiol Sante Publique 2005; 53:361-72. [PMID: 16353511 DOI: 10.1016/s0398-7620(05)84618-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND For twenty years, most of industrial countries developed recommendations on regionalization of perinatal care. Perinatal regionalization is particularly aimed at improving morbidity and mortality outcomes of low birth weight newborns by transferring pregnant women to the maternity units having a medical or neonatal environment suited to the risks incurred by mothers or babies. Perinatal regionalization cannot be effective without being well accepted by the majority of professionals. The objectives of this study were then to identify professionals'expectations and objections to perinatal regionalisation and to compare them from a professional group to another one. METHODS Professionals of 3 French perinatal networks were under consideration: the Rhône, the Auvergne and the Gard-Lozère networks. The study included two stages: 1) a psychosociological qualitative study, based on professionals'interviews, aimed at identifying main concerns of professionals and developing a questionnaire; then 2) an epidemiological quantitative study, using this questionnaire within French networks. In the questionnaire, 8 dimensions explored the professionals'views: constraints related to regulation aspects and to the setting up of maternity units care levels, risk of loss of professionals' competence and prestige, consequences on medical practices, on inter-professional relationship, on work organization and financial aspects, and related to the new role of 'private practice'professionals, legal consequences. RESULTS The response rate of the epidemiological study was 80%. The results permitted to construct 8 dimension scores describing the reasons of poor acceptability of regionalization. After taking into account the age, the sex, the network and the juridical status of the institution, the study revealed a significant poorer acceptability of regionalization by most of medical specialty groups (anesthetists, obstetricians, midwives and "private practice" professionals) compared with neonatologists, or by "private" professionals (professionals working in private clinics and "private practice" professionals) compared with professionals working in university or community hospitals. The study described also network setting up conditions related to its functioning. CONCLUSION By identifying clearly professionals 'objections and expectations, this study should facilitate improvement in the organization of studied perinatal networks.
Collapse
Affiliation(s)
- S David
- Service de Biostatistiques des Hospices Civils de Lyon, 162, avenue Lacassagne, 69003 Lyon.
| | | | | | | | | | | | | | | |
Collapse
|
324
|
Epstein AJ, Rathore SS, Krumholz HM, Volpp KGM. Volume-based referral for cardiovascular procedures in the United States: a cross-sectional regression analysis. BMC Health Serv Res 2005; 5:42. [PMID: 15935099 PMCID: PMC1175086 DOI: 10.1186/1472-6963-5-42] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 06/03/2005] [Indexed: 11/26/2022] Open
Abstract
Background We sought to estimate the numbers of patients affected and deaths avoided by adopting the Leapfrog Group's recommended hospital procedure volume minimums for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). In addition to hospital risk-adjusted mortality standards, the Leapfrog Group recommends annual hospital procedure minimums of 450 for CABG and 400 for PCI to reduce procedure-associated mortality. Methods We conducted a retrospective analysis of a national hospital discharge database to evaluate in-hospital mortality among patients who underwent PCI (n = 2,500,796) or CABG (n = 1,496,937) between 1998 and 2001. We calculated the number of patients treated at low volume hospitals and simulated the number of deaths potentially averted by moving all patients to high volume hospitals under best-case conditions (i.e., assuming the full volume-associated reduction in mortality and the capacity to move all patients to high volume hospitals with no related harms). Results Multivariate adjusted odds of in-hospital mortality were higher for patients treated in low volume hospitals compared with high volume hospitals for CABG (OR 1.16, 95% CI 1.10–1.24) and PCI (OR 1.12, 95% CI 1.05–1.20). A policy of hospital volume minimums would have required moving 143,687 patients for CABG and 87,661 patients for PCI from low volume to high volume hospitals annually and prevented an estimated 619 CABG deaths and 109 PCI deaths. Thus, preventing a single death would have required moving 232 CABG patients or 805 PCI patients from low volume to high volume hospitals. Conclusion Recommended hospital CABG and PCI volume minimums would prevent 728 deaths annually in the United States, fewer than previously estimated. It is unclear whether a policy requiring the movement of large numbers of patients to avoid relatively few deaths is feasible or effective.
Collapse
Affiliation(s)
- Andrew J Epstein
- Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saif S Rathore
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Kevin GM Volpp
- Center for Health Equity Research and Promotion, Philadelphia Veterans' Affairs Hospital, Philadelphia, Pennsylvania, USA
- Department of Health Care Systems, Wharton School of Business, and Section of General Internal Medicine, Department of Medicine, School of Medicine, both at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
325
|
Dimick JB, Finlayson SRG, Birkmeyer JD. Regional availability of high-volume hospitals for major surgery. Health Aff (Millwood) 2005; Suppl Variation:VAR45-53. [PMID: 15471773 DOI: 10.1377/hlthaff.var.45] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite evidence of increased risks, a large number of patients still have surgery in low-volume hospitals. To better understand why, we used Medicare data to study the regional availability of high-volume hospitals. More than half of patients undergoing three procedures in low-volume hospitals lived in regions lacking a high-volume hospital. Some regions simply lacked enough cases to support a high-volume hospital. Other regions had enough cases but too many hospitals performing them. Although consolidation of surgical services may be feasible in some settings, volume-based referral strategies are impractical for many U.S. regions.
Collapse
Affiliation(s)
- Justin B Dimick
- Veterans Affairs (VA) Outcomes Group, VA Medical Center, Vermont, USA.
| | | | | |
Collapse
|
326
|
Losina E, Barrett J, Baron JA, Levy M, Phillips CB, Katz JN. Utilization of low-volume hospitals for total hip replacement. ACTA ACUST UNITED AC 2005; 51:836-42. [PMID: 15478142 DOI: 10.1002/art.20700] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify factors associated with utilization of low-volume hospitals for total hip replacement (THR) and to estimate differences in the distances that Medicare beneficiaries had to travel to reach low- or high-volume hospitals. METHODS We studied a population-based sample of 1,146 Medicare beneficiaries who underwent elective THR in 1995. Using multiple data sources including medical record review, Medicare claims data, 1990 Census data, and a patient survey, we examined factors independently associated with utilization of low-volume hospitals for elective THR. We estimated the magnitude of difference in distances for patients undergoing THR in low- and high-volume hospitals. We determined the distance between each patient's residence and the treating hospital using MapQuest. RESULTS Rural residency, low income, and low educational attainment, as well as belief in the importance of convenient location in the choice of hospital, were associated with higher utilization of low-volume hospitals. Rural and suburban patients who went to low-volume hospitals traveled much less than patients operated upon in high-volume centers. CONCLUSION Policies aimed at restricting THR to high-volume centers would differentially affect poor, less educated, and rural patients. Voluntary efforts to shift THR to high-volume centers should involve educating these patients and their referring physicians about differences in both short-term and longer-term outcomes between high- and low-volume centers.
Collapse
Affiliation(s)
- Elena Losina
- Boston University School of Public Health and Robert B. Brigham Arthritis Clinical Research Center, Boston, Massachusetts, USA.
| | | | | | | | | | | |
Collapse
|
327
|
Abraham NS, Davila JA, Rabeneck L, Berger DH, El-Serag HB. Increased use of low anterior resection for veterans with rectal cancer. Aliment Pharmacol Ther 2005; 21:35-41. [PMID: 15644043 DOI: 10.1111/j.1365-2036.2004.02286.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Two surgical procedures with curative intent are available to patients with rectal cancer: lower anterior resection and abdominoperineal resection; however, lower anterior resection may improve quality of life and functional status. AIM To examine temporal changes in after lower anterior resection and abdominoperineal resection between 1989 and 2000. Potential factors associated with the use of lower anterior resection were evaluated. METHODS Using national administrative data, we identified patients who received lower anterior resection or abdominoperineal resection. Logistic regression models examined the association between use of lower anterior resection and time period of surgical resection. RESULTS A total of 5201 rectal cancer patients underwent resection. The use of lower anterior resection increased from 40.0% (1989-91) to 50.1% (1998-2000) paralleled by a corresponding decline in abdominoperineal resection (60.1 to 49.9%; P < 0.001). Patients who received surgery during 1992-94, 1995-97 and 1998-2000 were 6, 7 and 28% more likely to receive lower anterior resection, when compared with 1989-1991 after adjusting for demographic characteristics, co-morbidity and hospital surgical volume. Older age, lower co-morbidity score and lower hospital surgical volume were predictive of lower anterior resection. CONCLUSIONS An increase in the use of lower anterior resection for rectal cancer was observed over time. This observed increase in use is not confined to high-volume hospitals.
Collapse
Affiliation(s)
- N S Abraham
- Houston Center for Quality of Care and Utilization Studies, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | | | | | |
Collapse
|
328
|
Losina E, Plerhoples T, Fossel AH, Mahomed NN, Barrett J, Creel AH, Wright EA, Katz JN. Offering patients the opportunity to choose their hospital for total knee replacement: Impact on satisfaction with the surgery. ACTA ACUST UNITED AC 2005; 53:646-52. [PMID: 16208651 DOI: 10.1002/art.21469] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the extent to which patients were offered a choice between 2 or more hospitals for total knee replacement (TKR); to examine the association between having a choice of hospital for TKR and satisfaction with the surgery; and to identify population groups less likely to be offered a choice. METHODS We studied a population-based sample of 932 Medicare beneficiaries who underwent elective TKR in 2000. We surveyed patients about their participation in choosing a hospital and their satisfaction with surgery. We examined whether lack of hospital choice influenced satisfaction with surgery after adjusting for age, sex, preoperative function, and socioeconomic status. RESULTS Among 932 TKR recipients (mean age 74 years, 67% women), more than half (53%) reported having a lack of hospital choice. After adjusting for socioeconomic status, patients reporting lack of choice were approximately twice as likely to be dissatisfied with the results of surgery as patients who reported choosing among 2 or more hospitals for TKR (odds ratio [OR] 2.09, 95% confidence interval [95% CI] 1.13-3.87). Results of logistic regression revealed that patients reporting lack of choice were more likely to be women (OR 1.52, 95% CI 1.14-2.04), >80 years of age (as compared with 65-70 years; OR 1.63, 95% CI 1.03-2.57), living in suburban areas (OR 1.68, 95% CI 1.23-2.30), nonwhite (OR 1.57, 95% CI 0.86-2.87), and were less likely to have TKR performed by a high-volume surgeon (OR 0.71, 95% CI 0.53-0.96). CONCLUSION More than half of the patients did not have a choice in selecting the hospital where they had TKR. Patients reporting lack of choice were more likely to be dissatisfied with surgery. Interventions to address preferences for hospital may improve satisfaction with care for patients with advanced knee arthritis.
Collapse
Affiliation(s)
- Elena Losina
- Boston University School of Public Health, and Robert Brigham Arthritis and Musculoskeletal Clinical Research Center, MA 02118, USA.
| | | | | | | | | | | | | | | |
Collapse
|
329
|
Ward MM, Jaana M, Wakefield DS, Ohsfeldt RL, Schneider JE, Miller T, Lei Y. What would be the effect of referral to high-volume hospitals in a largely rural state? J Rural Health 2004; 20:344-54. [PMID: 15551851 DOI: 10.1111/j.1748-0361.2004.tb00048.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Volume of certain surgical procedures has been linked to patient outcomes. The Leapfrog Group and others have recommended evidence-based referral using specific volume thresholds for nonemergent cases. The literature is limited on the effect of such referral on hospitals, especially in rural areas. PURPOSE To examine the impact of evidence-based referral by volume standard for 5 hospital procedures (abdominal aortic artery repair, coronary angioplasty, coronary artery bypass graft, esophageal cancer surgery, and pancreatic resection) in a largely rural state. METHODS Healthcare Cost and Utilization Project Iowa State Inpatient Dataset was analyzed to identify hospitals meeting the volume standard versus those not meeting the standard. FINDINGS Relatively few hospitals perform these procedures in Iowa. Hospitals performing the procedures at a volume above the threshold standard set by the Leapfrog Group tend to be larger, receive more transfers from other hospitals for these procedures, and perform fewer of these procedures on an emergency basis. In Iowa, hospitals that met the volume standard did not differ from hospitals that did not meet the volume standard in risk-adjusted mortality rates. The impact of evidence-based referral would be substantial in terms of travel time for some procedures (ie, coronary artery bypass graft, pancreatic resection, and esophageal cancer surgery) and produce considerable lost revenue for some hospitals. CONCLUSIONS Evidence-based referral would be associated with substantial burden for some patients and hospitals in Iowa. This negative impact does not appear to be offset by improvement in in-hospital mortality rates. These initial findings suggest that there are a number of issues that need to be considered, especially in a rural state, before evidence-based referral is embraced as a means to enhance patient outcomes.
Collapse
Affiliation(s)
- Marcia M Ward
- Department of Health Management and Policy, University of Iowa, Iowa City, Iowa 52242-1008, USA.
| | | | | | | | | | | | | |
Collapse
|
330
|
Haan CK, Adams M, Cook R. Improving the Quality of Data in Your Database: Lessons from a Cardiovascular Center. ACTA ACUST UNITED AC 2004; 30:681-8. [PMID: 15646101 DOI: 10.1016/s1549-3741(04)30081-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Creating and having a database should not be an end goal but rather a source of valid data and a means for generating information by which to assess process, performance, and outcome quality. The Cardiovascular Center at Shands Jacksonville (Florida) made measurable improvements in the quality of data in national registries and internally available software tools for collection of patient care data. METHODS The process of data flow was mapped from source to report submission to identify input timing and process gaps, data sources, and responsible individuals. Cycles of change in data collection and entry were developed and the improvements were tracked. RESULTS Data accuracy was improved by involving all caregivers in datasheet completion and assisting them with data-field definitions. Using hospital electronic databases decreased the need for manual retrospective review of medical records for datasheet completion. The number of fields with missing values decreased by 83.6%, and the number of missing values decreased from 31.2% to 1.9%. Data accuracy rose dramatically by realtime data entry at point of care. DISCUSSION Key components to ensuring data quality for process and outcome improvement are (1) education of the caregiver team, (2) process supervision by a database manager, (3) commitment and explicit support from leadership,(4) increased and improved use of electronic data sources, and (5) data entry at point of care.
Collapse
Affiliation(s)
- Constance K Haan
- System Outcomes and Effectiveness, University of Florida, Jacksonville, USA.
| | | | | |
Collapse
|
331
|
Abstract
We develop and validate a method to measure "market capture" of inpatient, elective surgery. Data envelopment analysis (DEA) is used to measure the efficiency of the market capture for Perioperative Services at 53 non-metropolitan Pennsylvania hospitals. Eight procedures are studied, representing a wide spectrum of elective, scheduled, inpatient surgery (e.g., abdominal aortic aneurysm resection and hip replacement). Our results address issues in operating room management, such as: How should additional resources be allocated to each surgical specialty? Given existing market conditions, for which specialties can we expect to be able to increase our current workloads? Our results demonstrate DEA's potential as a valuable tool for operating room managers' strategic decision-making.
Collapse
Affiliation(s)
- Liam O'Neill
- Department of Policy Analysis and Management, Sloan Program of Health Management, 105 MVR Hall, Cornell University, Ithaca, NY 14853-4401, USA.
| | | |
Collapse
|
332
|
Epstein AJ, Rathore SS, Volpp KGM, Krumholz HM. Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000: does the evidence support current procedure volume minimums? J Am Coll Cardiol 2004; 43:1755-62. [PMID: 15145095 PMCID: PMC2803067 DOI: 10.1016/j.jacc.2003.09.070] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2003] [Revised: 09/15/2003] [Accepted: 09/23/2003] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate current American College of Cardiology/American Heart Association (ACC/AHA) hospital percutaneous coronary intervention (PCI) volume minimum recommendations. BACKGROUND In order to reduce procedure-associated mortality, ACC/AHA guidelines recommend that hospitals offering PCIs perform at least 400 PCIs annually. It is unclear whether this volume standard applies to current practice. METHODS We conducted a retrospective analysis of the Agency for Healthcare Research and Quality's Nationwide In-patient Sample hospital discharge database to evaluate in-hospital mortality among patients (n = 362748) who underwent PCI between 1998 and 2000 at low (5 to 199 cases/year), medium (200 to 399 cases/year), high (400 to 999 cases/year), and very high (1000 cases or more/year) PCI volume hospitals. RESULTS Crude in-hospital mortality rates were 2.56% in low-volume hospitals, 1.83% in medium-volume hospitals, 1.64% in high-volume hospitals, and 1.36% in very high-volume hospitals (p < 0.001 for trend). Compared with patients treated in high-volume hospitals (odds ratio [OR] 1.00, referent), patients treated in low-volume hospitals remained at increased risk for mortality after adjustment for patient characteristics (OR 1.21, 95% confidence interval [CI] 1.06 to 1.28). However, patients treated in medium-volume hospitals (OR 1.02, 95% CI 0.92 to 1.14) and patients treated in very high-volume hospitals (OR 0.94, 95% CI 0.85 to 1.03) had a comparable risk of mortality. Findings were similar when high- and very high-volume hospitals were pooled together. CONCLUSIONS We found no evidence of higher in-hospital mortality in patients undergoing PCI at medium-volume hospitals compared with patients treated at hospitals with annual PCI volumes of 400 cases of more, suggesting current ACC/AHA PCI hospital volume minimums may merit reevaluation.
Collapse
Affiliation(s)
- Andrew J Epstein
- Department of Health Care Systems, Wharton School of Business, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | |
Collapse
|
333
|
Smith ER, Butler WE, Barker FG. Craniotomy for Resection of Pediatric Brain Tumors in the United States, 1988 to 2000: Effects of Provider Caseloads and Progressive Centralization and Specialization of Care. Neurosurgery 2004; 54:553-63; discussion 563-5. [PMID: 15028128 DOI: 10.1227/01.neu.0000108421.69822.67] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2003] [Accepted: 11/06/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Large provider caseloads are associated with better patient outcomes after many complex surgical procedures. Mortality rates for pediatric brain tumor surgery in various practice settings have not been described. We used a national hospital discharge database to study the volume-outcome relationship for craniotomy performed for pediatric brain tumor resection, as well as trends toward centralization and specialization.
METHODS
We conducted a cross sectional and longitudinal cohort study using Nationwide Inpatient Sample data for 1988 to 2000 (Agency for Healthcare Research and Quality, Rockville, MD). Multivariate analyses adjusted for age, sex, geographic region, admission type (emergency, urgent, or elective), tumor location, and malignancy.
RESULTS
We analyzed 4712 admissions (329 hospitals, 480 identified surgeons) for pediatric brain tumor craniotomy. The in-hospital mortality rate was 1.6% and decreased from 2.7% (in 1988–1990) to 1.2% (in 1997–2000) during the study period. On a per-patient basis, median annual caseloads were 11 for hospitals (range, 1–59 cases) and 6 for surgeons (range, 1–32 cases). In multivariate analyses, the mortality rate was significantly lower at high-volume hospitals than at low-volume hospitals (odds ratio, 0.52 for 10-fold larger caseload; 95% confidence interval, 0.28–0.94; P = 0.03). The mortality rate was 2.3% at the lowest-volume-quartile hospitals (4 or fewer admissions annually), compared with 1.4% at the highest-volume-quartile hospitals (more than 20 admissions annually). There was a trend toward lower mortality rates after surgery performed by high-volume surgeons (P = 0.16). Adverse hospital discharge disposition was less likely to be associated with high-volume hospitals (P < 0.001) and high-volume surgeons (P = 0.004). Length of stay and hospital charges were minimally related to hospital caseloads. Approximately 5% of United States hospitals performed pediatric brain tumor craniotomy during this period. The burden of care shifted toward large-caseload hospitals, teaching hospitals, and surgeons whose practices included predominantly pediatric patients, indicating progressive centralization and specialization.
CONCLUSION
Mortality and adverse discharge disposition rates for pediatric brain tumor craniotomy were lower when the procedure was performed at high-volume hospitals and by high-volume surgeons in the United States, from 1988 to 2000. There were trends toward lower mortality rates, greater centralization of surgery, and more specialization among surgeons during this period.
Collapse
Affiliation(s)
- Edward R Smith
- Massachusetts General Hospital, and Department of Surgery (Neurosurgery), Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | |
Collapse
|
334
|
Rathore SS, Epstein AJ, Volpp KGM, Krumholz HM. Hospital coronary artery bypass graft surgery volume and patient mortality, 1998-2000. Ann Surg 2004; 239:110-7. [PMID: 14685108 PMCID: PMC1356200 DOI: 10.1097/01.sla.0000103066.22732.b8] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the association between annual hospital coronary artery bypass graft (CABG) surgery volume and in-hospital mortality. SUMMARY BACKGROUND DATA The Leapfrog Group recommends health care purchasers contract for CABG services only with hospitals that perform >or=500 CABGs annually to reduce mortality; it is unclear whether this standard applies to current practice. METHODS We conducted a retrospective analysis of the National Inpatient Sample database for patients who underwent CABG in 1998-2000 (n = 228738) at low (12-249 cases/year), medium (250-499 cases/year), and high (>or=500 cases/year) CABG volume hospitals. Crude in-hospital mortality rates were 4.21% in low-volume hospitals, 3.74% in medium-volume hospitals, and 3.54% in high-volume hospitals (trend P < 0.001). Compared with patients at high-volume hospitals (odds ratio 1.00, referent), patients at low-volume hospitals remained at increased risk of mortality after multivariable adjustment (odds ratio 1.26, 95% confidence interval = 1.15-1.39). The mortality risk for patients at medium-volume hospitals was of borderline significance (odds ratio 1.11, 95% confidence interval = 1.01-1.21). However, 207 of 243 (85%) of low-volume and 151 of 169 (89%) of medium-volume hospital-years had risk-standardized mortality rates that were statistically lower or comparable to those expected. In contrast, only 11 of 169 (6%) of high-volume hospital-years had outcomes that were statistically better than expected. CONCLUSIONS Patients at high-volume CABG hospitals were, on average, at a lower mortality risk than patients at lower-volume hospitals. However, the small size of the volume-associated mortality difference and the heterogeneity in outcomes within all CABG volume groups suggest individual hospital CABG volume is not a reliable marker of hospital CABG quality.
Collapse
Affiliation(s)
- Saif S Rathore
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | |
Collapse
|
335
|
Affiliation(s)
- Kazim Sheikh
- U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, 601 East 12th Street, Room 235, Kansas City, MO 64106, USA.
| |
Collapse
|
336
|
Bullock DP, Sporer SM, Shirreffs TG. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am 2003; 85:1981-6. [PMID: 14563808 DOI: 10.2106/00004623-200310000-00018] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have demonstrated an increased rate of perioperative complications and morbidity following simultaneous bilateral total knee arthroplasty compared with the rate following unilateral total knee arthroplasty. The purpose of this study was to compare the rate of perioperative complications and morbidity associated with simultaneous bilateral total knee arthroplasty with that associated with unilateral total knee arthroplasty. METHODS The records on all bilateral total knee arthroplasties performed between January 1994 and June 2000 and unilateral total knee arthroplasties performed between January 1995 and June 2000 were retrospectively reviewed. The records on 514 unilateral total knee arthroplasties and 255 bilateral total knee arthroplasties were analyzed to determine demographic information, preoperative comorbidities, perioperative complications, and thirty-day and one-year mortality rates. RESULTS The rates of some perioperative complications, including myocardial infarction, postoperative confusion, and the need for intensive monitoring, were greater after the bilateral arthroplasties. However, the thirty-day and one-year mortality rates and the risks of pulmonary embolism, infection, and deep venous thrombosis were similar for the two groups. CONCLUSIONS The risk of perioperative complications associated with bilateral simultaneous total knee arthroplasty was slightly increased compared with that associated with unilateral total knee arthroplasty, but the mortality rates were similar. Ultimately, the decision to proceed with simultaneous knee replacement should depend on patient preference through informed choice.
Collapse
Affiliation(s)
- Daniel P Bullock
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA
| | | | | |
Collapse
|
337
|
Allen SW, Gauvreau K, Bloom BT, Jenkins KJ. Evidence-based referral results in significantly reduced mortality after congenital heart surgery. Pediatrics 2003; 112:24-8. [PMID: 12837863 DOI: 10.1542/peds.112.1.24] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Significant interinstitutional variation in mortality after congenital heart surgery has been demonstrated. Noting an association between reduced mortality and higher volume, a center with a small annual case volume began in August 1998 to selectively refer to high-volume surgical centers based on published or "apparent" low mortality rates for specific cardiac lesions. This study was undertaken to evaluate the effect of evidence-based referral in this practice. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort comparison over a 10-year period for a small Midwestern pediatric cardiology practice. The institutional database was retrospectively reviewed for children (<18 years) undergoing surgery from August 1992 to July 2002. Data were divided into 3 time periods (August 1992 to July 1995, period 1; August 1995 to July 1998, period 2; and August 1998 to July 2002, period 3). Hospital discharge abstract data from 5 states (California, Illinois, Massachusetts, Pennsylvania, and Washington) in 1992, 1996, and 1998 provided contemporaneous benchmarks. Risk adjustment was performed using the Risk Adjustment in Congenital Heart Surgery-1 method. Risk category, age at surgery, prematurity, and major noncardiac structural anomaly were entered into a multivariate logistic regression model to compare in-hospital mortality adjusting for case-mix differences. RESULTS A total of 514 congenital heart surgical cases were identified from August 1992 to July 2002; 507 cases (98.6%) were assigned to a risk category and analyzed further. Unadjusted in-hospital mortality rates were 9.3% in period 1, 5.9% in period 2, and 1.3% in period 3. Unadjusted mortality rates for cases from benchmark data were 6.4% in 1992, 4.8% in 1996, and 3.7% in 1998. Risk adjusted mortality was comparable to the benchmark data in periods 1 and 2, but superior outcomes (odds ratio = 0.24) were demonstrated in period 3. CONCLUSIONS Evidence-based referrals from a small-volume pediatric cardiac center to large-volume institutions resulted in a reduction in mortality after congenital heart surgery.
Collapse
Affiliation(s)
- Steven W Allen
- Pediatric Cardiology, Wichita Clinic, Wichita, Kansas 67208, USA.
| | | | | | | |
Collapse
|
338
|
|
339
|
Abstract
Numerous reports have documented a volume-outcome relationship for complex medical and surgical care, although many such studies are compromised by the use of discharge abstract data, inadequate risk adjustment, and problematic statistical methodology. Because of the volume-outcome association, and because valid outcome measurements are unavailable for many procedures, volume-based referral strategies have been advocated as an alternative approach to health-care quality improvement. This is most appropriate for procedures with the greatest outcome variability between low-volume and high-volume providers, such as esophagectomy and pancreatectomy, and for particularly high-risk subgroups of patients. Whenever possible, risk-adjusted outcome data should supplement or supplant volume standards, and continuous quality improvement programs should seek to emulate the processes of high-volume, high-quality providers. The Leapfrog Group has established a minimum volume requirement of 500 procedures for coronary artery bypass grafting. In view of the questionable basis for this recommendation, we suggest that it be reevaluated.
Collapse
Affiliation(s)
- David M Shahian
- Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA.
| | | |
Collapse
|
340
|
Katz JN, Phillips CB, Baron JA, Fossel AH, Mahomed NN, Barrett J, Lingard EA, Harris WH, Poss R, Lew RA, Guadagnoli E, Wright EA, Losina E. Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery. ARTHRITIS AND RHEUMATISM 2003; 48:560-8. [PMID: 12571867 DOI: 10.1002/art.10754] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate whether hospital volume and surgeon volume of total hip replacements (THRs) are associated with patient-reported functional status and satisfaction with surgery 3 years postoperatively. METHODS We performed a population-based cohort study of a stratified random sample of Medicare beneficiaries who underwent elective primary or revision THR in Ohio, Pennsylvania, or Colorado in 1995. The primary outcomes were the self-reported Harris hip score and a validated scale measuring satisfaction with the results of surgery. Both outcomes were assessed 3 years postoperatively. Hospital volume was defined as the aggregate number of elective primary and revision THRs performed on Medicare beneficiaries in the hospital in 1995. High-volume hospitals were defined as those in which >100 such procedures are performed annually, and low-volume centers were defined as those in which </=12 procedures (primary THR cohort) or </=30 procedures (revision cohort) are performed annually. RESULTS In unadjusted analyses, patients who underwent surgery in low-volume centers had worse functional status 3 years following primary and revision THR compared with patients whose surgery was performed in higher-volume centers. Patients whose revision THR was performed by a low-volume surgeon also had worse function. After adjustment for sociodemographic and clinical variables, however, the association between higher hospital volume and better functional status following primary THR was weak and statistically nonsignificant, and no statistically significant or clinically important associations between hospital or surgeon volume and functional status following revision THR was observed. Patients who underwent elective primary THR in low-volume centers were more likely to be dissatisfied with the results of surgery compared with patients whose surgeries were performed in high-volume centers. Similarly, patients whose surgeons performed </=12 procedures per year were more likely to be dissatisfied with the results of revision THR than were patients whose surgeons performed >12 procedures per year. CONCLUSION Hospital volume and surgeon volume have little effect on 3-year functional outcome following THR, after adjusting for patient sociodemographic and select clinical characteristics. However, satisfaction with primary THR is greater among patients who underwent surgery in high-volume centers, and satisfaction with revisions is greater among patients whose operations were performed by higher-volume surgeons. Referring clinicians should incorporate these findings into their discussion of referral choices with patients considering THR. Conclusions regarding the effect of volume on longevity of the implants must await longer-term followup studies. Finally, further research is warranted to better understand the association between hospital and surgeon procedure volume and patient satisfaction with surgery.
Collapse
Affiliation(s)
- Jeffrey N Katz
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, B-3, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
341
|
Slim K, Flamein R, Chipponi J. [Relation between activity volume and surgeon's results: myth or reality?]. ANNALES DE CHIRURGIE 2002; 127:502-11. [PMID: 12404844 DOI: 10.1016/s0003-3944(02)00817-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retrieved and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated. A new approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.
Collapse
Affiliation(s)
- K Slim
- Service de chirurgie générale et digestive, Hôtel-Dieu, boulevard Léon-Malfreyt, 63058 Clermont-Ferrand, France.
| | | | | |
Collapse
|
342
|
Ko CY, Chang JT, Chaudhry S, Kominski G. Are high-volume surgeons and hospitals the most important predictors of in-hospital outcome for colon cancer resection? Surgery 2002; 132:268-73. [PMID: 12219022 DOI: 10.1067/msy.2002.125721] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although recent studies have reported that high-volume surgeons and hospitals have better outcomes for colon cancer resections, it remains unclear whether there are other factors that are more important than volume. This study aims to evaluate the importance of the volume variables relative to other factors in an attempt to target specific areas for improving outcomes. METHODS Using nationwide data from the Healthcare Cost and Utilization Program, full-model logistic regression was performed on all patients undergoing colon cancer resection. In hospital mortality was regressed against more than 30 different independent variables, including demographic factors (eg, age, gender, race, ethnicity, and socioeconomic status), burden of morbid and comorbid disease (prevalence and severity), and provider variables (eg, hospital size, location, teaching status, hospital and surgeon volume). A separate baseline probability analysis was then performed to compare the relative importance for all predictor variables. RESULTS The sample size for this analysis was 22,408; 622 in-hospital deaths occurred (2.8%). Average age was 70 years old, 51% of particIpants were male, and 60% had at least 1 comorbid disease. An operation was elective (64%), urgent (19%), or emergency (15%). The significant predictors for mortality (at P <.05) included age, gender, comorbid disease (ie, cardiovascular, pulmonary, liver), operation severity (ie, emergency, urgent), and volume (both hospital and surgeon). The baseline probability analysis shows that the mortality for a baseline case is 12/1000. If this baseline case goes to a high-volume hospital or surgeon, the mortality will decrease to 11/1000 and 10/1000, respectively. If a patient with a baseline case of colon cancer also has coexistent liver disease or requires an emergency operation, mortality increases to 44/1000 and 45/1000, respectively. Overall, the volume variables, although statistically significant, have a relatively smaller effect on outcome compared with other factors. CONCLUSIONS Whereas other factors have a stronger association with outcome than volume, volume is the only acutely mutable variable. Although the regionalization controversy (ie, using only high-volume surgeons or hospitals) is not solved with our findings, this study elucidates and compares the relative importance of several different factors on outcome, which is essential when considering the conclusions and implications of this type of policy-relevant outcomes research.
Collapse
Affiliation(s)
- Clifford Y Ko
- Department of Surgery, UCLA School of Medicine and Public Health, 90095, USA
| | | | | | | |
Collapse
|
343
|
Padmanabhan RS, Byrnes MC, Helmer SD, Smith RS. Should Esophagectomy be Performed in a Low-Volume Center? Am Surg 2002. [DOI: 10.1177/000313480206800407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
A significant difference has been reported between rates of morbidity and mortality for elective esophagectomy performed at low-volume centers versus high-volume centers. Some authors have suggested that complex surgical procedures such as esophagectomy should be performed only in regional centers by surgeons with an extensive procedure-specific experience. This study was performed to review recent (5 years) experience with esophagectomy in two university-affiliated hospitals where a limited number of esophageal resections are performed annually. Esophageal resections performed between February 1995 and February 2000 at two university-affiliated tertiary-care hospitals were analyzed for operative morbidity and mortality. Variables reviewed included demographics, surgeon experience, mortality, and complications. Forty-three patients underwent elective esophagectomy during the 5-year study period. In-hospital mortality was 7.0 per cent and 30-day mortality was 4.7 per cent. The anastomotic leak rate was 11.6 per cent. No patients developed myocardial infarction or renal failure. Morbidity and mortality rates from our low-volume centers compared favorably with high-volume centers. We conclude that elective esophagectomy can be safely performed at low-volume centers with favorable morbidity and mortality rates. Recommendations urging regionalization of high-risk procedures should be guided by local outcomes and not by the total number of procedures performed at a specific center.
Collapse
Affiliation(s)
- Rajesh S. Padmanabhan
- Department of Surgery, University of Kansas School of Medicine—Wichita, Wichita, Kansas
| | - Matthew C. Byrnes
- Department of Surgery, University of Kansas School of Medicine—Wichita, Wichita, Kansas
| | - Stephen D. Helmer
- Department of Surgery, University of Kansas School of Medicine—Wichita, Wichita, Kansas
| | - R. Stephen Smith
- Department of Surgery, University of Kansas School of Medicine—Wichita, Wichita, Kansas
| |
Collapse
|
344
|
Chang RKR, Klitzner TS. Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 2002; 109:173-81. [PMID: 11826192 DOI: 10.1542/peds.109.2.173] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The association between high case volumes and better patient outcomes has been demonstrated for many surgical procedures and medical treatments, including surgery for children with congenital heart disease. To simulate the effects of regionalization of pediatric cardiac surgery, we assessed the impact of reducing the number of pediatric cardiac centers on surgical mortality and patient's travel distance. METHODS This study used abstracted statewide hospital discharge data from California from 1995 to 1997. Case volume and in-hospital mortality for pediatric cardiac surgeries at each hospital were calculated. All hospitals that performed > or =10 pediatric cardiac surgeries in 1995 to 1997 were included in the analysis. To simulate regionalization, we "closed" the hospital with the lowest case volume and redistributed patients from this hospital to the nearest remaining hospitals. The number of in-hospital deaths was then recalculated using the original mortality rate of each remaining hospital multiplied by its new case volume. A multivariate logistic regression was conducted to determine the odds ratios of mortality of various types of surgery compared with closure of ventricular septal defect. This result was used for adjusting for the case-mix of the hospitals. Regionalization simulation analysis was repeated, and the number of deaths was recalculated using this adjustment of hospital case-mix. We also examined the increase in travel distance of patients to the hospitals as a result of the regionalization simulation. RESULTS In California, 6592 children underwent cardiac surgeries in 1995 to 1997 with 352 in-hospital deaths (overall mortality rate: 5.34%). A quadratic regression model demonstrated that a high surgical volume was associated with a low mortality rate. We found demarcations between low- and medium-volume hospitals at 70 cases per year and medium- and high-volume hospitals at 170 cases per year. With adjustment for hospital case-mix, we found that 41 deaths could be avoided when all patients from low-volume hospitals were referred, and 83 deaths could be avoided when all patients from low- and medium-volume hospitals were referred to high-volume hospitals (overall mortality rate decreased to 4.08%). The average travel distance for pediatric cardiac surgery was 45.4 miles, which increased by 12.7 miles when all surgeries were referred to high-volume hospitals. When only the 733 high-risk patients were referred from low- and medium-volume hospitals to high-volume hospitals, 49 deaths could be avoided, yielding an overall mortality rate of 4.60%. CONCLUSIONS Theoretical regionalization of pediatric cardiac surgery is associated with a reduction in surgical mortality from 5.34% to 4.08% when all cases were referred to high-volume hospitals, or decrease to 4.60% when high-risk cases were referred. Although regionalization is associated with an important decrease in the number of deaths, it also increases the travel distance for patients. Additional studies on the costs and benefits of regionalization are needed to determine the best strategies to improve outcomes for children who undergo cardiac surgery.
Collapse
Affiliation(s)
- Ruey-Kang R Chang
- Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
| | | |
Collapse
|
345
|
Shaffer CF. Factors influencing the access to prenatal care by Hispanic pregnant women. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2002; 14:93-6. [PMID: 11892542 DOI: 10.1111/j.1745-7599.2002.tb00097.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To explore factors influencing the access to prenatal care among Hispanic pregnant women living in the United States. DATA SOURCES A convenience sample of 46 Hispanic migrant pregnant women was interviewed over a 12-month period using a set of five open-ended questions. CONCLUSIONS The ability of the health care providers to communicate in Spanish, as well as the availability of culturally sensitive prenatal care were the main factors influencing the willingness of Hispanic women to access to prenatal care. IMPLICATIONS FOR PRACTICE With the Hispanic population increasing in the United States, there is a need to provide culturally appropriate health care for that population; prenatal care is one of the areas of health care in demand. This study supports the findings in the literature and provides nurse practitioners a deeper understanding of the needs of Hispanic women needing prenatal care.
Collapse
|
346
|
Abstract
This article describes why rural residents migrate or travel outside their local market area for specialty physician care. Data were collected through a random mail survey of persons residing in Iowa's rural counties. The results imply that migration for specialty care is not simply a function of a low perceived availability of local specialty physicians. Managers of rural and urban health care systems may need to rethink the extent to which specialty physician services should be distributed across rural markets.
Collapse
Affiliation(s)
- T F Borders
- School of Medicine, Texas Tech University HSC, Lubbock, Texas, USA.
| | | |
Collapse
|
347
|
Abstract
Associations between hospital volume or physician caseload and patient outcome have been used to assess the performance of health care providers. Although most studies have focused on major surgical procedures, in-hospital or 30-day mortality from many nonsurgical conditions and procedures has also been examined. Although high volume may be a surrogate for the provider's skill and experience, and better outcomes may attract greater volumes, aggregate data on provider volume show many outliers indicating that the outcome for some low-volume providers is better than that for high-volume providers. Mortality is only one measure of medical care quality. Although high volume may not always be indicative of favorable outcome, referral of patients from low-volume to high-volume providers has been recommended. It has also been suggested that patients choose health care providers on the basis of physician caseload. It is unclear how such recommendations could be implemented in practice; furthermore, they would deprive many patients from access to, as well as disrupt the provision of, adequate health care in many areas. An alternative to requiring patients to receive care from high-volume providers is to adopt other measures for improving outcomes, such as improving the quality of care provided by low-volume providers and attracting better providers to low-volume areas.
Collapse
Affiliation(s)
- K Sheikh
- Centers for Medicare & Medicaid Services, United States Department of Health and Human Services, Kansas City, Missouri 64106, USA
| |
Collapse
|
348
|
Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am 2001; 83:1622-9. [PMID: 11701783 DOI: 10.2106/00004623-200111000-00002] [Citation(s) in RCA: 519] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The mortality and complication rates of many surgical procedures are inversely related to hospital procedure volume. The objective of this study was to determine whether the volumes of primary and revision total hip replacements performed at hospitals and by surgeons are associated with rates of mortality and complications. METHODS We analyzed claims data of Medicare recipients who underwent elective primary total hip replacement (58,521 procedures) or revision total hip replacement (12,956 procedures) between July 1995 and June 1996. We assessed the relationship between surgeon and hospital procedure volume and mortality, dislocation, deep infection, and pulmonary embolus in the first ninety days postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, comorbid conditions, and income. Analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume. RESULTS Twelve percent of all primary total hip replacements and 49% of all revisions were performed in centers in which ten or fewer of these procedures were carried out in the Medicare population annually. In addition, 52% of the primary total hip replacements and 77% of the revisions were performed by surgeons who carried out ten or fewer of these procedures annually. Patients treated with primary total hip replacement in hospitals in which more than 100 of the procedures were performed per year had a lower risk of death than those treated with primary replacement in hospitals in which ten or fewer procedures were performed per year (mortality rate, 0.7% compared with 1.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.38, 0.89). Patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96). CONCLUSIONS Patients treated at hospitals and by surgeons with higher annual caseloads of primary and revision total hip replacement had lower rates of mortality and of selected complications. These analyses of Medicare claims are limited by a lack of key clinical information such as operative details and preoperative functional status.
Collapse
Affiliation(s)
- J N Katz
- Robert B Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, Bostn, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
349
|
Birkmeyer JD, Finlayson EV, Birkmeyer CM. Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative. Surgery 2001; 130:415-22. [PMID: 11562662 DOI: 10.1067/msy.2001.117139] [Citation(s) in RCA: 424] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND As part of a broader effort aimed at improving hospital safety, a large coalition of employers, the Leapfrog Group, will soon require hospitals caring for their employees to meet volume standards for 5 high-risk surgical procedures. We estimated the potential benefits of full nationwide implementation of these volume standards. METHODS. Using data from Nationwide Inpatient Sample and other sources, we first estimated the total number of each of the 5 procedures-coronary-artery bypass graft, abdominal aortic aneurysm repair, coronary angioplasty, esophagectomy, and carotid endarterectomy-performed each year in hospitals in US metropolitan areas. (Leapfrog exempts hospitals in rural areas to avoid access issues.) We then projected the effectiveness of volume standards (in terms of relative risks of mortality) for each procedure using data from a published structured literature review. RESULTS With full implementation nationwide, the Leapfrog volume standards would save 2581 lives. Of the procedures, volume standards would save the most lives with coronary-artery bypass graft (1486), followed by abdominal aortic-aneurysm repair (464), coronary angioplasty (345), esophagectomy (168), and carotid endarterectomy (118). In our estimates of the number of lives saved, we considered assumptions about how many patients would be affected and the effectiveness of volume standards (ie, strength of underlying volume-outcome relationships with each procedure). CONCLUSIONS If the Leapfrog volume standards are successfully implemented, employers and health-care purchasers could prevent many surgical deaths by requiring hospital volume standards for high-risk procedures.
Collapse
Affiliation(s)
- J D Birkmeyer
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA
| | | | | |
Collapse
|
350
|
Abstract
BACKGROUND Population-based studies have demonstrated better outcomes for carotid endarterectomies at high-volume hospitals. METHODS This is a 2-year retrospective review of carotid procedures at two low-volume hospitals (n = 156) and one high-volume hospital (n = 404) in the metropolitan area of Portland, Oregon. RESULTS There were no significant differences in 30-day mortality and stroke rates for carotid endarterectomies when comparing low- and high-volume hospitals (P = 0.59). These were comparable rates despite the fact that the low-volume hospitals had significantly older patients (P <0.001), more smokers (P <0.001), more patients with an indication of a previous nondisabling stroke (P <0.01), and fewer patients who were asymptomatic (P <0.01). CONCLUSION The regionalization of carotid endarterectomy into high-volume hospitals is not justified by the findings of this study. Carotid endarterectomy performed by well-trained, experienced surgeons in low-volume hospitals is a safe procedure.
Collapse
Affiliation(s)
- C Peck
- Foundation for Accountability, Oregon Health Science University, 9155 SW Barnes Rd, Suite 304, Portland, OR 97225, USA
| | | | | |
Collapse
|