Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System?

Care cascades following low-value cervical cancer screening in dually enrolled Veterans

BACKGROUND

Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare.

METHODS

This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting.

RESULTS

Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare.

CONCLUSIONS

Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.

Veterans Affairs Medical Center Racial and Ethnic Composition and Initiation of Anticoagulation for Atrial Fibrillation

Importance

Racial and ethnic disparities exist in anticoagulation therapy for atrial fibrillation (AF). Whether medical center racial and ethnic composition is associated with these disparities is unclear.

Objective

To determine whether medical center racial and ethnic composition is associated with overall anticoagulation and disparities in anticoagulation for AF.

Design, Setting, and Participants

Retrospective cohort study of Black, White, and Hispanic patients with incident AF from 2018 to 2021 at 140 Veterans Health Administration medical centers (VAMCs). Data were analyzed from March to November 2023.

Exposure

VAMC racial and ethnic composition, defined as the proportion of patients from minoritized racial and ethnic groups treated at a VAMC, categorized into quartiles. VAMCs in quartile 1 (Q1) had the lowest percentage of patients from minoritized groups (ie, the reference group).

Main Outcomes and Measures

The odds of initiating any anticoagulant, direct-acting oral anticoagulant (DOAC), or warfarin therapy within 90 days of an index AF diagnosis, adjusting for sociodemographics, medical comorbidities, and facility factors.

Results

The cohort comprised 89 791 patients with a mean (SD) age of 73.0 (10.1) years; 87 647 (97.6%) were male, 9063 (10.1%) were Black, 3355 (3.7%) were Hispanic, and 77 373 (86.2%) were White. Overall, 64 770 individuals (72.1%) initiated any anticoagulant, 60 362 (67.2%) initiated DOAC therapy, and 4408 (4.9%) initiated warfarin. Compared with White patients, Black and Hispanic patients had lower rates of any anticoagulant and DOAC therapy initiation but higher rates of warfarin initiation across all quartiles of VAMC racial and ethnic composition. Any anticoagulant therapy initiation was lower in Q4 than Q1 (69.8% vs 74.9%; adjusted odds ratio [aOR], 0.80; 95% CI, 0.69-0.92; P < .001). DOAC and warfarin initiation were also lower in Q4 than in Q1 (DOAC, 69.4% vs 65.3%; aOR, 0.85; 95% CI, 0.74-0.97; P < .001; warfarin, 5.4% vs 4.5%; aOR, 0.82; 95% CI, 0.67-1.00; P < .001). In adjusted models, patients in Q4 were significantly less likely to initiate any anticoagulant therapy than those in Q1 (aOR, 0.88; 95% CI, 0.78-0.99). Patients in Q3 (aOR, 0.75; 95% CI, 0.60-0.93) and Q4 (aOR, 0.69; 95% CI, 0.55-0.87) were significantly less likely to initiate warfarin therapy than those in Q1. There was no significant difference in the adjusted odds of initiating DOAC therapy across racial and ethnic composition quartiles. Although significant Black-White and Hispanic-White differences in initiation of any anticoagulant, DOAC, and warfarin therapy were observed, interactions between patient race and ethnicity and VAMC racial composition were not significant.

Conclusions and Relevance

In a national cohort of VA patients with AF, initiation of any anticoagulant and warfarin, but not DOAC therapy, was lower in VAMCs serving more minoritized patients.

National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration

INTRODUCTION

The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA.

METHODS

A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics.

RESULTS

Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions.

CONCLUSIONS

Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

Frontline perspectives of C. difficile infection prevention practice implementation within veterans affairs health care facilities: A qualitative study

BACKGROUND

In 2012, the veteran's affairs (VA) multidrug-resistant organism (MDRO) Program Office launched a national Clostridioides difficile Infection (CDI) Prevention Initiative to address CDI as the most common cause of healthcare associated infections, mandating use of a VA CDI Bundle of prevention practices in inpatient facilities. We draw upon frontline worker perspectives to explore work system barriers and facilitators to the sustained implementation of the VA CDI Bundle using the systems engineering initiative for patient safety (SEIPS) framework.

METHODS

We interviewed 29 key stakeholders at 4 participating sites between October 2019-July 2021. Participants included infection prevention and control (IPC) leaders, nurses, physicians, and environmental management staff. Interviews were analyzed to identify themes and perceptions of facilitators and barriers to CDI prevention.

RESULTS

IPC leadership was most likely to know of the specific VA CDI Bundle components. Other participants demonstrated general knowledge of CDI prevention practices, with role-based variation in the depth of awareness of specific practices. Facilitators included leadership support, mandated CDI training and prevention practices, and readily available training from multiple sources. Barriers included limits to communication about facility or unit-level CDI rates, ambiguous communications about CDI prevention practice updates and VA mandates, and role-hierarchies that may limit team members' clinical contributions.

DISCUSSION

Recommendations include improving centrally-mandated clarity about and standardization of CDI prevention policies, including testing. Regular IPC training updates for all clinical stakeholders are also recommended.

CONCLUSIONS

A work system analysis using SEIPS identified barriers and facilitators to CDI prevention practices that could be addressed both nationally at the system level and locally at the facility level, specifically in the areas of communication and coordination.

Navigated intramedullary nailing for patients with intertrochanteric hip fractures is cost-effective at high-volume hospitals in mainland China: A markov decision analysis

Objective

Previous studies have reported that navigation systems can improve clinical outcomes of intramedullary nailing (IMN) for patients with intertrochanteric fractures. However, information is lacking regarding the relationship between the costs of navigated systems and clinical outcomes. The present research aimed to evaluate the cost-effectiveness of navigated IMN as compared with traditional freehand IMN for patients with intertrochanteric fractures.

Methods

A Markov decision model with a 5-year time horizon was constructed to investigate the costs, clinical outcomes and incremental cost-effectiveness ratio (ICER) of navigated IMN for a 70-year-old patient with an intertrochanteric fracture in mainland China. The costs [Chinese Yuan (¥)], health utilities (quality-adjusted life-years, QALYs) and transition probabilities were obtained from published studies. The willingness-to-pay threshold for ICER was set at ¥1,40,000/QALY following the Chinese gross domestic product in 2020. Three institutional surgical volumes were used to determine the average navigation-related costs per patient: low volume (100 cases), medium volume (200 cases) and high volume (300 cases).

Results

Institutes at which 300, 200 and 100 cases of navigated IMN were performed per year showed an ICER of ¥43,149/QALY, ¥76,132.5/QALY and ¥1,75,083/QALY, respectively. Navigated IMN would achieve cost-effectiveness at institutes with an annual volume of more than 125 cases.

Conclusions

Our analysis demonstrated that the navigated IMN could be cost-effective for patients with inter-trochanteric fracture as compared to traditional freehand IMN. However, the cost-effectiveness was more likely to be achieved at institutes with a higher surgical volume.

Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems

Importance

Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades.

Objective

To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services.

Design, Setting, and Participants

This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022.

Exposures

Receipt of low-value PSA testing.

Main Outcomes and Measures

Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates.

Results

This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA.

Conclusions and Relevance

The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.

Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments.

INTRODUCTION

An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation.

METHODS

We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome.

RESULTS

There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk.

CONCLUSIONS

There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

Large Surgical Databases with Direct Data Abstraction: VASQIP and ACS-NSQIP

Direct data abstraction from a patient's chart by experienced medical professional data abstractors has been the historical gold standard for quality and accuracy in clinical medical research. The limiting challenge to population-wide studies for quality and public health purposes is the high personnel costs associated with very large-scale efforts of this type. Two historically related programs that are at least partially able to successfully circumvent this problem and provide high-quality data relating to surgical procedures and the early postoperative period are reviewed in this article. Both utilize similar data abstraction efforts by specially trained and qualified medical abstractors of a sample subset of the total procedures performed at participating hospitals.The Veterans Affairs Surgical Quality Improvement Program (VASQIP), detailed by Nicholas J. Giori, MD, PhD, in the first section of this article, makes use of trained abstractors and has undergone recent additions and updates, including the development of an associated total hip registry for the VA system. The data elements and data integrity provided by both of these programs establish important benchmarks for other "big data" efforts, which often attempt to use alternative less-expensive methods of data collection in order to achieve more widespread or even nationwide data collection.In the second section, Elizabeth B. Habermann, PhD, MPH, provides a detailed review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the data elements collected, and examples of the range of quality improvement and outcomes studies in orthopaedic surgery that it has made possible, along with information on data that have not been collected and the resulting limitations. The ACS NSQIP was actually modeled after the very similar earlier effort started by the United States Department of Veterans Affairs (VA).

Determination of risk factors of postoperative pneumonia in elderly patients with hip fracture: What can we do?

BACKGROUND

Postoperative pneumonia is a serious complication in elderly patients with hip fracture. It is necessary to identify the influencing factors of postoperative pneumonia in patients with hip fracture.

METHODS

Elderly patients with hip fractures admitted to a tertiary hospital in China from January 1, 2020 to August 31, 2021 were included. The characteristics of patients with and without postoperative pneumonia were evaluated and compared. Logistic multivariate regression analyses were conducted to assess the risk factors of postoperative pneumonia.

RESULTS

267 patients with hip fracture were included, the incidence of postoperative pneumonia in patients with hip fracture was 13.11%. There were significant differences in the age, diabetes mellitus, anemia, hypoalbuminemia, anesthesia method and duration of surgery between infection and no infection group, no significant differences in the gender, BMI, hypertension, hyperlipidemia, type of fracture, preoperative oxygen saturation, white blood cell count, platelet count, red blood cell count, creatinine, alanine aminotransferase, aspartate aminotransferase, estimated blood loss during surgery were detected between infection and no infection group. Logistic regression analysis showed that age≥70y (OR2.326, 95%CI1.248~3.129), diabetes mellitus (OR2.123, 95%CI1.021~3.551), anemia (OR3.199,95%CI1.943~5.024), hypoalbuminemia (OR2.377, 95%CI1.211~3.398), general anesthesia (OR1.947, 95%CI1.115~3.038), duration of surgery≥120min (OR1.621, 95%CI1.488~2.534) were the risk factors of postoperative pneumonia in elderly patients with hip fracture (all p<0.05). Escherichia Coli (33.33%), Klebsiella pneumoniae (28.57%), Staphylococcus aureus (21.43%) were the most common bacteria of pulmonary infection.

CONCLUSION

There are many risk factors for postoperative pneumonia in elderly patients with hip fractures after surgery. In clinical practice, medical workers should take targeted interventions for those risk factors to reduce postoperative pneumonia.

The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

Methods

Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery.

Results

Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001).

Conclusion

Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391.

Annual case volume is a risk factor for 30-day unplanned readmission after open reduction and internal fixation of acetabular fractures

BACKGROUND

Surgical fixation of acetabular fractures is technically challenging, and quality of reduction directly correlates to patient outcomes. Considering the difficulty of open reduction and internal fixation (ORIF), increased case volumes may improve patient outcomes. No studies have investigated case volume as a risk factor for readmission after acetabular fracture ORIF. The present study sought to answer the question of whether annual case volume is a risk factor for 30-day unplanned readmission after acetabular fracture ORIF, if there is an identifiable threshold number of cases most predictive of a readmission, and if differences exist between reasons for readmission between high and low-volume centers.

HYPOTHESIS

Institutions with a lower annual case volume will have a higher incidence of 30-day unplanned readmissions.

MATERIALS AND METHODS

The national readmissions database (NRD) was queried for acetabular fractures that underwent ORIF during 2016. Comorbid conditions were summed, and annual hospital case volume was identified. A receiver operating characteristic (ROC) curve was generated and the Youden index identified threshold case volume most predictive of a 30-day readmission. A multivariable logistic regression was performed with 30-day readmission as the dependent variable and case volume below the threshold an independent variable.

RESULTS

A total of 3,407 cases were included with a median age of 43. The 30-day readmission for this cohort was 6.5% (220/3407). ROC curve analysis identified 22 annual cases as the threshold value most predictive of 30-day readmission. Multivariable logistic regression identified age (Odds Ratio (OR)=1.01, p=0.005), number of comorbidities (OR=1.35, p<0.0001), and ≤22 cases (OR=1.50, p=0.006) as statistically significant risk factors for 30-day readmission. The most common reason for readmission at both high and low-volume centers was surgical site infection.

DISCUSSION

Annual case volume is a statistically significant predictor of 30-day readmission after acetabular fracture ORIF. Performing ≤22 acetabular ORIFs places patients at greater risk for a readmission. Patients at low-volume centers may be predisposed to readmission, and it is paramount to optimize patients prior to discharge, and have appropriate surgeon and hospital resources to treat these complex injuries.

LEVEL OF EVIDENCE

III, Cross-sectional study.