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Sarap MD. Quality and Value in Rural Cancer Care. Am Surg 2022; 88:1749-1753. [PMID: 35430908 DOI: 10.1177/00031348221086801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 60 million people reside in rural America with only 10% of US general surgeons providing for their surgical care. Rural cancer care has been maligned in the literature due to a lack of understanding of local resource limitations and to the difficulties involved in documenting the quality of local cancer care in small and rural communities. A majority of US cancer patients are diagnosed and treated in community cancer programs, many of which are Commission on Cancer Accredited and deliver care that is of high quality and value. The article discusses the components of high quality health care and offers suggestions for solo or small group rural surgeons to assist in collection of their own quality data and comparison to national benchmarks. One small rural program in Appalachian Ohio is used for a best-case example.
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Affiliation(s)
- Michael D Sarap
- 21457Southeastern Ohio Regional Medical Center, Cambridge, OH, USA
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2
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Abstract
The article describes the barriers rural surgeons face when attempting to measure, analyze, and benchmark the quality and value of the care they provide for their patients. Examples of suboptimal care are presented as well as special geographic and resource-related circumstances for many of these disparities of care. The article includes in-depth descriptions of the American College of Surgeons (ACS) Optimal Resources for Surgical Quality and Safety Program and the ACS Rural Hospital Surgical Verification and Quality Improvement Program. The article concludes by discussing several documented clinical, economic, and social advantages of keeping surgical care local.
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Affiliation(s)
- Michael Duke Sarap
- SE Med Department of Surgery, Cambridge, OH, USA; American College of Surgeons, Advisory Council for Rural Surgery; Commission on Cancer Program in Ohio; Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA; Lake Erie College of Medicine, Erie, PA, USA; Physicians Assistant Program, Marietta College; Tina Kiser Cancer Concern Coalition.
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3
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Eng OS, Blakely AM, Lafaro KJ, Fournier KF, Fackche NT, Johnston FM, Dineen S, Powers B, Hendrix R, Lambert LA, Ronnekleiv-Kelly S, Walle KV, Grotz TE, Leiting JL, Patel SH, Dhar VK, Baumgartner JM, Lowy AM, Clarke CN, Mogal H, Zaidi MY, Staley CA, Kimbrough C, Cloyd JM, Lee B, Raoof M. Institutional variation in recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: An opportunity for enhanced recovery pathways. J Surg Oncol 2020; 122:980-985. [PMID: 32627199 DOI: 10.1002/jso.26099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers. METHODS Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models. RESULTS A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P < .001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P < .001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%. CONCLUSIONS Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.
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Affiliation(s)
- Oliver S Eng
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Andrew M Blakely
- Department of Surgery, National Cancer Institute, Bethesda, Maryland
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Keith F Fournier
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Nadege T Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sean Dineen
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Benjamin Powers
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Ryan Hendrix
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Laura A Lambert
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | | | - Kara Vande Walle
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Travis E Grotz
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Sameer H Patel
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Vikrom K Dhar
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joel M Baumgartner
- Department of Surgery, University of California at San Diego, San Diego, California
| | - Andrew M Lowy
- Department of Surgery, University of California at San Diego, San Diego, California
| | - Callisia N Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Jordan M Cloyd
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Byrne Lee
- Department of Surgery, Stanford University, Palo Alto, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Drake TM, Lee MJ, Senapati A, Brown SR. Resource variation in colorectal surgery: a national centre level analysis. Colorectal Dis 2017; 19:641-648. [PMID: 28052574 DOI: 10.1111/codi.13596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/20/2016] [Indexed: 02/08/2023]
Abstract
AIM Delivery of quality colorectal surgery requires adequate resources. We set out to assess the relationship between resources and outcomes in English colorectal units. METHOD Data were extracted from the Association of Coloproctology of Great Britain and Ireland resource questionnaire to profile resources. This was correlated with Hospital Episode Statistics outcome data including 90-day mortality and readmissions. Patient satisfaction measures were extracted from the Cancer Experience Patient Survey and compared at unit level. Centres were divided by workload into low, middle and top tertile. RESULTS Completed questionnaires were received from 75 centres in England. Service resources were similar between low and top tertiles in access to Confidential Enquiry into Patient Outcome and Death (CEPOD) theatre, level two or three beds per 250 000 population or the likelihood of having a dedicated colorectal ward. There was no difference in staffing levels per 250 000 unit of population. Each 10% increase in the proportion of cases attempted laparoscopically was associated with reduced 90-day unplanned readmission (relative risk 0.94, 95% CI 0.91-0.97, P < 0.001). The presence of a dedicated colorectal ward (relative risk 0.85, 95% CI 0.73-0.99, P = 0.040) was also associated with a significant reduction in unplanned readmissions. There was no association between staffing or service factors and patient satisfaction. CONCLUSION Resource levels do not vary based on unit of population. There is benefit associated with increased use of laparoscopy and a dedicated surgical ward. Alternative measures to assess the relationship between resources and outcome, such as failure to rescue, should be explored in UK practice.
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Affiliation(s)
- T M Drake
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M J Lee
- Academic Unit of Surgical Oncology, Department of Oncology, University of Sheffield, Sheffield, UK.,Department of Colorectal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A Senapati
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - S R Brown
- Department of Colorectal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Ho V, Short MN, Aloia TA. Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery? Surgery 2017; 162:418-428. [PMID: 28438333 DOI: 10.1016/j.surg.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. METHODS Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. RESULTS Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. CONCLUSION Processes of care implemented when complications occur explain much of the surgeon volume-cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, TX; Department of Economics, Rice University, Houston, TX.
| | - Marah N Short
- Baker Institute for Public Policy, Rice University, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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Lemke M, Beyfuss K, Hallet J, Coburn NG, Law CHL, Karanicolas PJ. Patient Adherence and Experience with Extended Use of Prophylactic Low-Molecular-Weight Heparin Following Pancreas and Liver Resection. J Gastrointest Surg 2016; 20:1986-1996. [PMID: 27688212 DOI: 10.1007/s11605-016-3274-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective. METHODS An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH. RESULTS There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome. CONCLUSION Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines.
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Affiliation(s)
- Madeline Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Kaitlyn Beyfuss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Calvin H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Paul J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada.
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Søreide JA, Sandvik OM, Søreide K. Improving pancreas surgery over time: Performance factors related to transition of care and patient volume. Int J Surg 2016; 32:116-22. [PMID: 27373194 DOI: 10.1016/j.ijsu.2016.06.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/20/2016] [Accepted: 06/26/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pancreas surgery has evolved with better diagnostic imaging, changing indications, and improved patient selection. Outside high-volume tertiary centers, the documented effect of evolution in care and volumes are limited. Thus, we aimed to review indications and outcomes in pancreas surgery during the transition from community-based hospital to a university hospital. METHODS All pancreatic surgeries performed between 1986 and 2012 within a well-defined Norwegian population were identified from the hospital's database. Indications and postoperative outcomes, including mortality, were investigated. RESULTS Of the 219 included patients (54% males; median age, 64 years), 150 (69%) underwent pancreatoduodenectomy; 55 (25%), distal resection; and 5 (2%), enucleation. The annual number of operations increased during the study period (from <10/yr to >20/yr). Most patients (169; 77%) underwent surgery for suspected malignancy. The 30-day mortality decreased significantly over time among patients treated for pancreatic cancer (from 16.1% to 3.5%; p = 0.012). Over time, significant reductions in median hospitalization time (19 versus 12 days; p < 0.001), re-operation rate (37.1% versus 8.4%; p < 0.001), and median ICU stay (3 versus 0 days; p < 0.001) were observed. CONCLUSION The transition to university hospital and increase in volume has led to significant improvements in several performance metrics and reduced postoperative mortality. We believe improved perioperative management and focused, multidisciplinary care-bundles to be of importance.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Oddvar M Sandvik
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Healy MA, Grenda TR, Suwanabol PA, Yin H, Ghaferi AA, Birkmeyer JD, Wong SL. Colon cancer operations at high- and low-mortality hospitals. Surgery 2016; 160:359-65. [PMID: 27316824 PMCID: PMC4938751 DOI: 10.1016/j.surg.2016.04.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/07/2016] [Accepted: 04/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is wide variation in mortality across hospitals for cancer operations. While higher rates of mortality are commonly ascribed to high-risk resections, the impact on more common operations is unclear. We sought to evaluate causes of mortality following colon cancer operations across hospitals. METHODS Forty-nine American College of Surgeons Commission on Cancer hospitals were selected for participation in a Commission on Cancer special study. We ranked hospitals using a composite measure of mortality and performed onsite chart reviews. We examined patient characteristics and mortality following colon resections at very high-mortality and very low- mortality hospitals (2006-2007). RESULTS We identified 3,025 patients who underwent an operation at 19 low-mortality (n = 1,006) and 30 high-mortality (n = 2,019) hospitals. There were wide differences in risk-adjusted mortality between high-mortality and low-mortality hospitals (9.3% vs 2.4%; P < .001). Compared with low-mortality hospitals, high-mortality hospitals had more patients who were black (11.2% vs 6.5%; P < .001), had ≥2 comorbidities (22.7% vs 18.9%; P < .05), were categorized American Society of Anesthesiologists class 4-5 (11.9% vs 5.3%; P < .001), and were functionally dependent (13.9% vs 8.8%; P < .001). Rates of complication were similar in high-mortality versus low-mortality hospitals (odds ratio 1.29, 95% confidence interval, 0.85-1.95). For those experiencing complications, though, case fatality rates were significantly higher in high-mortality versus low-mortality hospitals (odds ratio 3.74, 95% confidence interval, 1.59-8.82). CONCLUSION There is significant variation in mortality across hospitals for colon cancer operations, despite similar perioperative morbidity. This finding reflects a need for improved operative decision-making to enhance outcomes and quality of care at these hospitals.
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Affiliation(s)
- Mark A Healy
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
| | - Tyler R Grenda
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | | | - Huiying Yin
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Amir A Ghaferi
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - John D Birkmeyer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Spence RT, Zargaran E, Hameed M, Nicol A, Navsaria P. An Objective Assessment of the Surgical Trainee in an Urban Trauma Unit in South Africa: A Pilot Study. World J Surg 2016; 40:1815-22. [PMID: 27091205 DOI: 10.1007/s00268-016-3503-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical outcomes are provider specific. This prospective audit describes the surgical activity of five general surgery residents on their trauma surgery rotation. It was hypothesized that the operating surgical trainee is an independent risk factor for adverse outcomes following major trauma. MATERIALS AND METHODS This is a prospective cohort study. All patients admitted, over a 6-month period (August 2014-January 2015), following trauma requiring a major operation performed by a surgical trainee at Groote Schuur Hospital's trauma unit in South Africa were included. Multiple logistic regression models were built to compare risk-adjusted surgical outcomes between trainees. The primary outcome measure was major in-hospital complications. RESULTS A total of 320 major operations involving 341 procedures were included. The mean age was 28.49 years (range 13-64), 97.2 % were male with a median ISS of 9 (IQR 1-41). Mechanism of injury was penetrating in 93.42 % of cases of which 51.86 % were gunshot injuries. Surgeon A consistently had the lowest risk-adjusted outcomes and was used as the reference for all outcomes in the regression models. Surgeon B, D, and E had statistically significant higher rates of major in-hospital complications than Surgeon A and C, after adjusting for multiple confounders. The final model used to calculate the risk estimates for the primary outcome had a ROC of 0.8649. CONCLUSION Risk-adjusted surgical outcomes vary by operating surgical trainee. The analysis thereof can add value to the objective assessment of a surgical trainee.
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Affiliation(s)
- Richard Trafford Spence
- Department of General Surgery, Codman Center Massachusetts General Hospital, Boston, USA.
- Department of General Surgery, University of Cape Town, Cape Town, South Africa.
| | - Eiman Zargaran
- Department of General Surgery, Vancouver General Hospital, Vancouver, Canada
- Department of General Surgery, University of British Columbia, Vancouver, Canada
| | - Morad Hameed
- Department of General Surgery, Vancouver General Hospital, Vancouver, Canada
- Department of General Surgery, University of British Columbia, Vancouver, Canada
| | - Andrew Nicol
- Department of General Surgery, University of Cape Town, Cape Town, South Africa
- Department of Trauma Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Pradeep Navsaria
- Department of General Surgery, University of Cape Town, Cape Town, South Africa
- Department of Trauma Surgery, Groote Schuur Hospital, Cape Town, South Africa
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Grenda TR, Revels SL, Yin H, Birkmeyer JD, Wong SL. Lung Cancer Resection at Hospitals With High vs Low Mortality Rates. JAMA Surg 2016; 150:1034-40. [PMID: 26267440 DOI: 10.1001/jamasurg.2015.2199] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Wide variations in mortality rates exist across hospitals following lung cancer resection; however, the factors underlying these differences remain unclear. OBJECTIVE To evaluate perioperative outcomes in patients who underwent lung cancer resection at hospitals with very high and very low mortality rates (high-mortality hospitals [HMHs] and low-mortality hospitals [LMHs]) to better understand the factors related to differences in mortality rates after lung cancer resection. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, 1279 hospitals that were accredited by the Commission on Cancer were ranked on a composite measure of risk-adjusted mortality following major cancer resections performed from January 1, 2005, through December 31, 2006. We collected data from January 1, 2006, through December 31, 2007, on 645 lung resections in 18 LMHs and 25 HMHs. After adjusting for patient characteristics, we used hierarchical logistic regression to examine differences in the incidence of complications and "failure-to-rescue" rates (defined as death following a complication). MAIN OUTCOMES AND MEASURES Rates of adherence to processes of care, incidence of complications, and failure to rescue following complications. RESULTS Among 645 patients who received lung resections (441 in LMHs and 204 in HMHs), the overall unadjusted mortality rates were 1.6% (n = 7) vs 10.8% (n = 22; P < .001) for LMHs and HMHs, respectively. Following risk adjustment, the difference in mortality rates was attenuated (1.8% vs 8.1%; P < .001) but remained significant. Overall, complication rates were higher in HMHs (23.3% vs 15.6%; adjusted odds ratio [aOR], 1.79; 95% CI, 0.99-3.21), but this difference was not significant. The likelihood of any surgical (aOR, 0.73; 95% CI, 0.26-2.00) or cardiopulmonary (aOR, 1.23; 95% CI, 0.70-2.16) complications was similar between LMHs and HMHs. However, failure-to-rescue rates were significantly higher in HMHs (25.9% vs 8.7%; aOR, 6.55; 95% CI, 1.44-29.88). CONCLUSIONS AND RELEVANCE Failure-to-rescue rates are higher at HMHs, which may explain the large differences between hospitals in mortality rates following lung cancer resection. This finding emphasizes the need for better understanding of the factors related to complications and their subsequent management.
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Affiliation(s)
- Tyler R Grenda
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Sha'Shonda L Revels
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Huiying Yin
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | | | - Sandra L Wong
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Scally CP, Yin H, Birkmeyer JD, Wong SL. Comparing perioperative processes of care in high and low mortality centers performing pancreatic surgery. J Surg Oncol 2015; 112:866-71. [DOI: 10.1002/jso.24085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/20/2015] [Indexed: 12/19/2022]
Affiliation(s)
- Christopher P. Scally
- Department of Surgery, University of Michigan; Center for Healthcare Outcomes and Policy; Ann Arbor Michigan
| | - Huiying Yin
- Department of Surgery, University of Michigan; Center for Healthcare Outcomes and Policy; Ann Arbor Michigan
| | - John D. Birkmeyer
- Department of Surgery, University of Michigan; Center for Healthcare Outcomes and Policy; Ann Arbor Michigan
| | - Sandra L. Wong
- Department of Surgery, University of Michigan; Center for Healthcare Outcomes and Policy; Ann Arbor Michigan
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James AC, Izard JP, Holt SK, Calvert JK, Wright JL, Porter MP, Gore JL. Root Causes and Modifiability of 30-Day Hospital Readmissions after Radical Cystectomy for Bladder Cancer. J Urol 2015; 195:894-9. [PMID: 26555956 DOI: 10.1016/j.juro.2015.10.175] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Radical cystectomy is associated with high complication and rehospitalization rates. An understanding of the root causes of hospital readmissions and the modifiability of factors contributing to readmissions may decrease the morbidity associated with radical cystectomy. We characterize the indications for rehospitalization following radical cystectomy, and determine whether these indications represent immutable patient disease and procedure factors or whether they are modifiable. MATERIALS AND METHODS From MarketScan® databases we identified patients younger than 65 years with a diagnosis of bladder cancer who underwent radical cystectomy between 2008 and 2011 and were readmitted to the hospital within 30 days of radical cystectomy. All associated ICD-9 codes in the index admission, subsequent outpatient claims and readmission claims were independently reviewed by 3 surgeons to determine a root cause of rehospitalization. Causes were broadly categorized as medical, surgical or infectious, and reviewers determined whether the readmission was modifiable. Multivariate logistical regression models were used to identify factors associated with rehospitalization. RESULTS A total of 1,163 patients were included in the study and 242 (21%) were readmitted to the hospital within 30 days. Of these readmissions 26% were considered modifiable (kappa=0.71). Of the nonmodifiable readmissions an infectious cause accounted for 52% and a medical cause accounted for 48%, whereas of the modifiable readmissions 62% were due to surgical causes, 30% to medical and 8% to infectious causes. On multivariate analysis only discharge to a skilled nursing facility was associated with modifiable (OR 6.12, 95% CI 2.32-16.14) or nonmodifiable (OR 3.27, 95% CI 1.63-6.53) hospital readmissions. CONCLUSIONS The majority of rehospitalizations after radical cystectomy are attributable its inherent morbidity. However, optimization of aspects of peri-cystectomy care could minimize the morbidity of radical cystectomy.
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Affiliation(s)
- Andrew C James
- Department of Urology, University of Kentucky School of Medicine, Lexington, Kentucky.
| | - Jason P Izard
- Department of Urology, Queens University, Kingston, Ontario, Canada
| | - Sarah K Holt
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - Joshua K Calvert
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - Jonathan L Wright
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - Michael P Porter
- Department of Urology, University of Washington School of Medicine, Seattle, Washington; Puget Sound Veterans Affairs Health Care System, Seattle, Washington
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
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Oldham KT, Fallat M, Barnhart D, Derkay C, Deshpande J, Georgeson K, Hirschl R, Houck C, Mooney D, Moss RL, Sawin R, Tuggle D. Reply to a Letter to the Editor. J Pediatr Surg 2015; 50:1434-6. [PMID: 26162971 DOI: 10.1016/j.jpedsurg.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/07/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Keith T Oldham
- American College of Surgeons Committee for Children's Surgery.
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