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Barnato AE, Johnson GR, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19. J Gen Intern Med 2022; 37:1996-2002. [PMID: 35412179 PMCID: PMC9002036 DOI: 10.1007/s11606-022-07530-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. OBJECTIVE To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. DESIGN Retrospective cohort analysis of manually abstracted electronic medical records. PATIENTS 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). KEY RESULTS Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). CONCLUSIONS Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, USA
| | | | - John D Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Sound Physicians, Tacoma, WA, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Economics, Dartmouth College, Hanover, NH, USA
| | - Allistair James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Barnato AE, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Treatment intensity and mortality among COVID-19 patients with dementia: A retrospective observational study. J Am Geriatr Soc 2022; 70:40-48. [PMID: 34480354 PMCID: PMC8742761 DOI: 10.1111/jgs.17463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID-19. METHODS This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID-19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do-not-resuscitate [DNR] orders) and in-hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%-20%, or high >20% ACP rates). RESULTS Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia-biased ACP billing practices (risk-adjusted ICU use: 21% vs. 30%, odds ratio [OR] = 0.6, p = 0.016; risk-adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). CONCLUSIONS Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID-19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference-sensitive" care for COVID-19.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - John D Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Sound Physicians, Tacoma, Washington, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Economics, Dartmouth College, Hanover, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Sacks OA, Barnato AE, Skinner JS, Birkmeyer JD, Fowler A, Birkmeyer N. Elevated Risk of COVID-19 Infection for Hospital-Based Health Care Providers. J Gen Intern Med 2021; 36:3642-3643. [PMID: 34405347 PMCID: PMC8370456 DOI: 10.1007/s11606-021-07088-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Olivia A Sacks
- Department of Surgery, Boston Medical Center, Boston, MA, USA.
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Economics, Dartmouth College, Hanover, NH, USA
| | | | | | - Nancy Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Abstract
Hospital admissions in the US fell dramatically with the onset of the coronavirus disease 2019 (COVID-19) pandemic. However, little is known about differences in admissions patterns among patient groups or the extent of the rebound. In this study of approximately one million medical admissions from a large, nationally representative hospitalist group, we found that declines in non-COVID-19 admissions from February to April 2020 were generally similar across patient demographic subgroups and exceeded 20 percent for all primary admission diagnoses. By late June/early July 2020, overall non-COVID-19 admissions had rebounded to 16 percent below prepandemic baseline volume (8 percent including COVID-19 admissions). Non-COVID-19 admissions were substantially lower for patients residing in majority-Hispanic neighborhoods (32 percent below baseline) and remained well below baseline for patients with pneumonia (-44 percent), chronic obstructive pulmonary disease/asthma (-40 percent), sepsis (-25 percent), urinary tract infection (-24 percent), and acute ST-elevation myocardial infarction (-22 percent). Health system leaders and public health authorities should focus on efforts to ensure that patients with acute medical illnesses can obtain hospital care as needed during the pandemic to avoid adverse outcomes.
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Affiliation(s)
- John D Birkmeyer
- John D. Birkmeyer is chief clinical officer of Sound Physicians, in Tacoma, Washington, and an adjunct professor for health policy and clinical practice, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire
| | - Amber Barnato
- Amber Barnato is a professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | - Nancy Birkmeyer
- Nancy Birkmeyer is principal research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | | | - Jonathan Skinner
- Jonathan Skinner is the James O. Freedman Presidential Professor in Economics at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
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Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM, Gaynor JW, Ghanayem N, Jacobs JP, Mayer JE, Ohye RG, Scheurer MA, Schwartz SM, Tabbutt S, Charpie JR. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2020; 74:2786-2795. [PMID: 31779793 DOI: 10.1016/j.jacc.2019.09.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. OBJECTIVES The purpose of this study was to determine whether outcomes improved over time within PC4. METHODS The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. RESULTS During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. CONCLUSIONS This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nikhil Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - J William Gaynor
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark A Scheurer
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven M Schwartz
- Departments of Pediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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6
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Barnato AE, O’Malley AJ, Skinner JS, Birkmeyer JD. Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study. J Hosp Med 2019; 14:229-231. [PMID: 30933674 PMCID: PMC6446938 DOI: 10.12788/jhm.3150] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/20/2018] [Indexed: 11/20/2022]
Abstract
We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated "surprise question" (SQ; "Would you be surprised if the patient died in the next year?") for inpatient admissions served to prime hospitalists and triggered an icon next to the patient's name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered "no" and 4.1% SQ-prompted who answered "yes" (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Corresponding Author: Amber E. Barnato, MD, MPH; E-mail: ; Telephone: 650-653-0829; Twitter: @abarnato
| | - A James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Economics, Dartmouth College, Hanover New Hampshire
| | - John D Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Sound Physicians, Tacoma, Washington
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7
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Chen LM, Norton EC, Banerjee M, Regenbogen SE, Cain-Nielsen AH, Birkmeyer JD. Spending On Care After Surgery Driven By Choice Of Care Settings Instead Of Intensity Of Services. Health Aff (Millwood) 2018; 36:83-90. [PMID: 28069850 DOI: 10.1377/hlthaff.2016.0668] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting.
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Affiliation(s)
- Lena M Chen
- Lena M. Chen is an assistant professor in the Department of Internal Medicine and at the Institute for Healthcare Policy and Innovation, University of Michigan Health System, and the Center for Healthcare Outcomes and Policy (CHOP), University of Michigan
| | - Edward C Norton
- Edward C. Norton is a professor of health management and policy in the School of Public Health, a professor of economics, a research associate at the National Bureau of Economic Research, and a professor at the Institute for Healthcare Policy and Innovation and at CHOP, University of Michigan Health System and University of Michigan
| | - Mousumi Banerjee
- Mousumi Banerjee is a research professor at the School of Public Health, and the Institute for Healthcare Policy and Innovation, and CHOP, University of Michigan Health System and University of Michigan
| | - Scott E Regenbogen
- Scott E. Regenbogen is an assistant professor of surgery, chief of the Division of Colorectal Surgery, and an assistant professor at the Institute for Healthcare Policy and Innovation and CHOP, University of Michigan Health System and University of Michigan
| | - Anne H Cain-Nielsen
- Anne H. Cain-Nielsen is a senior statistician in the Department of Surgery, the Institute for Healthcare Policy and Innovation, and CHOP, University of Michigan Health System and University of Michigan
| | - John D Birkmeyer
- John D. Birkmeyer was executive vice president of the Dartmouth-Hitchcock Health System, in Lebanon, New Hampshire, at the time this article was written
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Das A, Norton EC, Miller DC, Ryan AM, Birkmeyer JD, Chen LM. Adding A Spending Metric To Medicare's Value-Based Purchasing Program Rewarded Low-Quality Hospitals. Health Aff (Millwood) 2018; 35:898-906. [PMID: 27140997 DOI: 10.1377/hlthaff.2015.1190] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In fiscal year 2015 the Centers for Medicare and Medicaid Services expanded its Hospital Value-Based Purchasing program by rewarding or penalizing hospitals for their performance on both spending and quality. This represented a sharp departure from the program's original efforts to incentivize hospitals for quality alone. How this change redistributed hospital bonuses and penalties was unknown. Using data from 2,679 US hospitals that participated in the program in fiscal years 2014 and 2015, we found that the new emphasis on spending rewarded not only low-spending hospitals but some low-quality hospitals as well. Thirty-eight percent of low-spending hospitals received bonuses in fiscal year 2014, compared to 100 percent in fiscal year 2015. However, low-quality hospitals also began to receive bonuses (0 percent in fiscal year 2014 compared to 17 percent in 2015). All high-quality hospitals received bonuses in both years. The Centers for Medicare and Medicaid Services should consider incorporating a minimum quality threshold into the Hospital Value-Based Purchasing program to avoid rewarding low-quality, low-spending hospitals.
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Affiliation(s)
- Anup Das
- Anup Das is an MD/PhD student in the Department of Health Management and Policy at the University of Michigan, in Ann Arbor
| | - Edward C Norton
- Edward C. Norton is a professor in the Department of Health Management and Policy, the Department of Economics, and the Institute for Healthcare Policy and Innovation, all at the University of Michigan, and a research associate of the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - David C Miller
- David C. Miller is an associate professor in the Department of Urology and the Institute for Healthcare Policy and Innovation, both at the University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Health Management and Policy and the Institute for Healthcare Policy and Innovation, both at the University of Michigan
| | - John D Birkmeyer
- John D. Birkmeyer is executive vice president of the Dartmouth-Hitchcock Health System, in Hanover, New Hampshire
| | - Lena M Chen
- Lena M. Chen is an assistant professor in the Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, both at the University of Michigan, and a physician at the Veterans Affairs Ann Arbor Healthcare System, in Michigan
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Markar SR, Mackenzie H, Wiggins T, Askari A, Karthikesalingam A, Faiz O, Griffin SM, Birkmeyer JD, Hanna GB. Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions. Br J Surg 2017; 105:113-120. [DOI: 10.1002/bjs.10640] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/27/2017] [Accepted: 06/07/2017] [Indexed: 01/19/2023]
Abstract
Abstract
Background
In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.
Methods
The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997–2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed.
Results
Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia.
Conclusion
Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.
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Affiliation(s)
- S R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Wiggins
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College London, London, UK
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - A Karthikesalingam
- St George's Vascular Institute, St George's, University of London, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College London, London, UK
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - S M Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J D Birkmeyer
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
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10
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Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS. Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults. JAMA Surg 2017; 152:e170123. [PMID: 28329352 DOI: 10.1001/jamasurg.2017.0123] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and Relevance Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Anne H Cain-Nielsen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor3Department of Health Management and Policy, University of Michigan, Ann Arbor4Department of Economics, University of Michigan, Ann Arbor
| | - Lena M Chen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Integrated Delivery System, Dartmouth-Hitchcock, Hanover, New Hampshire6Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
| | - Jonathan S Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
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Friese CR, Xia R, Ghaferi A, Birkmeyer JD, Banerjee M. Hospitals In 'Magnet' Program Show Better Patient Outcomes On Mortality Measures Compared To Non-'Magnet' Hospitals. Health Aff (Millwood) 2016; 34:986-92. [PMID: 26056204 DOI: 10.1377/hlthaff.2014.0793] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hospital executives pursue external recognition to improve market share and demonstrate institutional commitment to quality of care. The Magnet Recognition Program of the American Nurses Credentialing Center identifies hospitals that epitomize nursing excellence, but it is not clear that receiving Magnet recognition improves patient outcomes. Using Medicare data on patients hospitalized for coronary artery bypass graft surgery, colectomy, or lower extremity bypass in 1998-2010, we compared rates of risk-adjusted thirty-day mortality and failure to rescue (death after a postoperative complication) between Magnet and non-Magnet hospitals matched on hospital characteristics. Surgical patients treated in Magnet hospitals, compared to those treated in non-Magnet hospitals, were 7.7 percent less likely to die within thirty days and 8.6 percent less likely to die after a postoperative complication. Across the thirteen-year study period, patient outcomes were significantly better in Magnet hospitals than in non-Magnet hospitals. However, outcomes did not improve for hospitals after they received Magnet recognition, which suggests that the Magnet program recognizes existing excellence and does not lead to additional improvements in surgical outcomes.
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Affiliation(s)
- Christopher R Friese
- Christopher R. Friese is an assistant professor in the School of Nursing at the University of Michigan, in Ann Arbor
| | - Rong Xia
- Rong Xia is a doctoral student in biostatistics in the School of Public Health at the University of Michigan
| | - Amir Ghaferi
- Amir Ghaferi is an assistant professor in the Department of Surgery and the Ross School of Business at the University of Michigan
| | - John D Birkmeyer
- John D. Birkmeyer is executive vice president at Enterprise Support Services and chief academic officer at the Dartmouth-Hitchcock Medical Center, in Hanover, New Hampshire
| | - Mousumi Banerjee
- Mousumi Banerjee is a research professor of biostatistics in the School of Public Health at the University of Michigan
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Bekelis K, Marth NJ, Wong K, Zhou W, Birkmeyer JD, Skinner J. Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times. JAMA Intern Med 2016; 176:1361-8. [PMID: 27455403 PMCID: PMC5434865 DOI: 10.1001/jamainternmed.2016.3919] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care. OBJECTIVES To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims. EXPOSURES Admission to a PSC. MAIN OUTCOMES AND MEASURES Seven-day and 30-day postadmission case-fatality rates. RESULTS Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, -2.1% to -1.4%) lower 7-day and 1.8% (95% CI, -2.3% to -1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care. CONCLUSIONS AND RELEVANCE Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Nancy J Marth
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Kendrew Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Weiping Zhou
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - John D Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire4Department of Economics, Dartmouth College, Hanover, New Hampshire
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Abstract
OBJECTIVE To measure the association between a surgeon's degree of specialization in a specific procedure and patient mortality. DESIGN Retrospective analysis of Medicare data. SETTING US patients aged 66 or older enrolled in traditional fee for service Medicare. PARTICIPANTS 25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13. MAIN OUTCOME MEASURE Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures). RESULTS For all four cardiovascular procedures and two out of four cancer resections, a surgeon's degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure. CONCLUSION For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon's procedure specific volume as well as the degree to which a surgeon specializes in that procedure.
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Affiliation(s)
- Nikhil R Sahni
- Department of Economics, Harvard University, Cambridge, MA, USA McKinsey and Company, Boston, MA, USA
| | - Maurice Dalton
- National Bureau of Economic Research, Cambridge, MA, USA
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, MA, USA National Bureau of Economic Research, Cambridge, MA, USA
| | - John D Birkmeyer
- Dartmouth-Hitchcock Health System, Lebanon, NH, USA Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Amitabh Chandra
- National Bureau of Economic Research, Cambridge, MA, USA Harvard Kennedy School, Cambridge, MA, USA
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Abstract
Best practices for reducing risks of postoperative infection, venous thromboembolism, and nausea and vomiting in patients undergoing laparoscopic surgery are uncertain. As a result, perioperative care varies widely. We reviewed evidence from randomized clinical trials on the effectiveness of interventions for postoperative infection, venous thromboembolism, and nausea and vomiting Data sources were the Cochrane Central Register of Clinical Trials, reference lists of published trials, and randomized clinical trials published in English since 1990. Trials were also limited to those focused on patients undergoing laparoscopic surgery. Data from 98 randomized clinical trials were included in the final analysis. Routine antibiotic use in laparoscopic cholecystectomy, and possibly other clean procedures not involving placement of prostheses, is likely unnecessary. Similarly, venous thromboembolism prophylaxis is probably unnecessary for low-risk patients undergoing brief procedures. Of a wide variety of methods for reducing postoperative nausea and vomiting, serotonin receptor antagonists appear the most effective and should be considered for routine prophylaxis.
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Affiliation(s)
- Aaron Goldfaden
- Michigan Surgical Collaborative for Outcomes Research and Evaluation, Department of Surgery, University of Michigan and Department of Surgery, St. Joseph Medical Center, Ann Arbor, MI 48109, USA
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Abstract
Bariatric surgery is the most effective treatment for achieving sustained weight loss in morbidly obese patients. Although the use of gastric bypass is growing rapidly, the potential life expectancy benefits of the procedure are unknown. We created a Markov decision analysis model to examine the effect of gastric bypass surgery on life expectancy in morbidly obese patients (body mass index [BMI] = 40 kg/m2). Input assumptions for the model were obtained from published life tables (baseline mortality risks), epidemiologic studies (obesity-related excess mortality), and large case series (surgical outcomes). In our baseline analysis, a 40-year-old woman (BMI = 40 kg/m2) would gain 2.6 years of life expectancy by undergoing gastric bypass (38.7 years versus 36.2 years without surgery). In sensitivity analysis, life-years gained with surgery remained substantial when assumptions were varied across reasonable ranges for surgical mortality risk (1.0-3.0 years) and effectiveness (0.9-4.4 years). Life-years gained with gastric bypass surgery did not vary considerably by age and sex subgroups. Relative to other major surgical procedures, gastric bypass for morbid obesity is associated with substantial gains in life expectancy. Long- term data from prospective studies are needed to confirm this finding.
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Affiliation(s)
- G Darby Pope
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA
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Abstract
A retrospective, single-center study was conducted to understand variation in mortality after elective cancer surgery. Fifty-two patients who died perioperatively after elective cancer resections (colon, esophageal, pancreatic, lung, gastric and liver) were identified. A methodology was developed and used during medical record review to capture the occurrence and chronology of 21 postoperative complications. Data were reviewed by 3 attending surgeons who assigned cause of death based on information from the entire clinical record. This methodology demonstrated good construct validity, with 81% agreement between cause of death assigned by expert review of data from the instrument and that assigned by expert review of the clinical records (κ = 0.75, P < .005). Cause-specific mortality can be reliably and systematically measured after cancer surgery. Understanding variation in cause-specific mortality can inform future quality improvement efforts.
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Affiliation(s)
- Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
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Abstract
IMPORTANCE Measures of surgeons' skills have been associated with variations in short-term outcomes after laparoscopic gastric bypass. However, the effect of surgical skill on long-term outcomes after bariatric surgery is unknown. OBJECTIVE To study the association between surgical skill and long-term outcomes of bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS In this retrospective observational study, 20 surgeons performing bariatric surgery submitted videos; surgeons were ranked on their skill level through blinded peer video review and sorted into quartiles of skill. Outcomes of bariatric surgery were then examined at the patient level across skill levels. The patients (N = 3631) undergoing surgery with these surgeons had 1-year postoperative follow-up data available between 2006 and 2012. The study was conducted using the Michigan Bariatric Surgery Collaborative, a prospective clinical registry of 40 hospitals performing bariatric surgery in the state of Michigan. EXPOSURE Surgeon skill level. MAIN OUTCOMES AND MEASURES Excess body weight loss at 1 year; resolution of medical comorbidities (hypertension, sleep apnea, diabetes, and hyperlipidemia), functional status, and patient satisfaction. RESULTS Surgeons in the top and bottom quartiles had each been practicing for a mean of 11 years. Peer ratings of surgical skill varied from 2.6 to 4.8 on a 5-point scale. There was no difference between the best (top 25%) and worst (bottom 25%) performance quartiles when comparing excess body weight loss (67.2% vs 68.5%; P = .86) at 1 year. There were no differences in resolution of sleep apnea (62.6% vs 62.0%; P = .77), hypertension (47.1% vs 45.4%; P = .73), or hyperlipidemia (52.3% vs 63.4%; P = .45). Surgeons with the lowest skill rating had patients with higher rates of diabetes resolution (78.8%) when compared with the high-skill group (72.8%) (P = .01). CONCLUSIONS AND RELEVANCE In contrast to its effect on early complications, surgical skill did not affect postoperative weight loss or resolution of medical comorbidities at 1 year after laparoscopic gastric bypass. These findings suggest that long-term outcomes after bariatric surgery may be less dependent on a surgeon's operative skill and instead be driven by other factors. Operative technique was not assessed in this analysis and should be considered in future studies.
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Affiliation(s)
- Christopher P Scally
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Oliver A Varban
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
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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 DOI: 10.1016/j.surg.2016.04.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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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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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20
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Abstract
OBJECTIVE To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy. DATA SOURCES National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy. STUDY DESIGN Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy. PRINCIPAL FINDINGS Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy. CONCLUSIONS This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
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Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Affiliation(s)
- Lena M. Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Center for Healthcare Outcomes & Policy, University of Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
| | - Edward C. Norton
- Institute for Healthcare Policy and Innovation, University of Michigan
- Department of Health Management & Policy, University of Michigan School of Public Health
- Department of Economics, University of Michigan
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - John D. Birkmeyer
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Affiliation(s)
- John D Birkmeyer
- From the Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy and Clinical Practice - both in Lebanon, NH
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Chen LM, Meara E, Birkmeyer JD. Medicare's Bundled Payments for Care Improvement initiative: expanding enrollment suggests potential for large impact. Am J Manag Care 2015; 21:814-820. [PMID: 26633254 PMCID: PMC4669886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Aiming to encourage care coordination and cost efficiency, the Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. To help gauge the program's potential impact and generalizability, we describe early and current participants. STUDY DESIGN We examined the cross-sectional association between BPCI participation and providers' structural and cost characteristics. METHODS Using data from October 2013 and June 2014, we quantified changes in BPCI participation. We described structural differences between participating and nonparticipating hospitals using t tests and χ2 tests, and we used the Cochrane-Armitage test to assess whether participants were more likely be in higher 90-day episode cost quintiles than their peers at baseline (2009-2010). RESULTS Overall (risk-bearing and non-risk-bearing) participation in BPCI increased from about 400 in October 2013 to more than 2000 in June 2014-attributable, in part, to Model 2, the most comprehensive of the 4 models offered by CMMI for provider participation. Model 2 hospitals increasingly resemble eligible but nonparticipating hospitals. For the most commonly chosen condition of hip replacement, Model 2 hospitals were not costlier than their peers. Hospitals used to make up 97% of Model 2 participants, but physician practices now comprise a substantial number of Model 2 participants. However, most BPCI participants have not yet begun to bear financial risk. Risk-bearing Model 2 hospitals are a smaller and less representative group, with higher baseline costs for hip replacement than their peers. CONCLUSIONS Growing participation in BPCI suggests strong interest in bundled payments. The long-term impact of BPCI will depend on CMMI's ability to persuade interested but non-risk-bearing participants to bear risk.
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Affiliation(s)
- Lena M Chen
- University of Michigan Division of General Medicine, North Campus Research Complex, 2800 Plymouth Rd, Bldg 16, Rm 407E, Ann Arbor, MI 48109-2800. E-mail:
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Scally C, Varban OA, Thumma JR, Birkmeyer JD, Dimick JB. Video Ratings of Surgical Skill and Late Outcomes after Bariatric Surgery. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE Colorectal cancer (CRC) is the second most expensive cancer in the United States. Episode-based bundled payments may be a strategy to decrease costs. However, it is unknown how payments are distributed across hospitals and different perioperative services. METHODS We extracted actual Medicare payments for patients in the fee-for-service Medicare population who underwent CRC surgery between January 2004 and December 2006 (N = 105,016 patients). Payments included all service types from the date of hospitalization up to 1 year later. Hospitals were ranked from least to most expensive and grouped into quintiles. Results were case-mix adjusted and price standardized using empirical Bayes methods. We assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment. RESULTS There is wide variation in total payments for CRC care within the first year after CRC surgery. Actual Medicare payments were $51,345 per patient in the highest quintile and $26,441 per patient in the lowest quintile, representing a difference of Δ = $24,902. Differences were persistent after price standardization (Δ = $17,184 per patient) and case-mix adjustment (Δ = $4,790 per patient). Payments for the index surgical hospitalization accounted for the largest share (65%) of payments but only minimally varied (11.6%) across quintiles. However, readmissions and postacute care services accounted for substantial variations in total payments. CONCLUSION Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization. This has significant implications for policy decisions on how to bundle payments and define episodes of surgical CRC care.
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Affiliation(s)
- Zaid M Abdelsattar
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; and Enterprise Support Services, Dartmouth-Hitchcock Health System, Lebanon, NH
| | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; and Enterprise Support Services, Dartmouth-Hitchcock Health System, Lebanon, NH
| | - Sandra L Wong
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; and Enterprise Support Services, Dartmouth-Hitchcock Health System, Lebanon, NH
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Schoenfeld AJ, Harris MB, Liu H, Birkmeyer JD. Variations in Medicare payments for episodes of spine surgery. Spine J 2014; 14:2793-8. [PMID: 25017141 PMCID: PMC4253551 DOI: 10.1016/j.spinee.2014.07.002] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/29/2014] [Accepted: 07/03/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals. PURPOSE To examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals. STUDY DESIGN All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included. PATIENT SAMPLE Included 185,954 episodes of spine surgery performed between 2005 and 2007. OUTCOME MEASURES Payments per episode of spine surgery. METHODS All patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment. RESULTS Episode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses. CONCLUSIONS Medicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care.
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Affiliation(s)
- Andrew J. Schoenfeld
- Robert Wood Johnson Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI 48109
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115
| | - Haiyin Liu
- Center for Healthcare Outcome and Policy, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109
| | - John D. Birkmeyer
- Center for Healthcare Outcome and Policy, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109
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Abstract
BACKGROUND There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization. OBJECTIVE To assess the impact of ASC opening on rates of outpatient surgery. DESIGN This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery. SUBJECTS Patients included were Medicare beneficiaries with Part B eligibility. MAIN OUTCOME MEASURE Adjusted HSA-level rates of outpatient surgery. RESULTS Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P<0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P<0.001 for test between 3 slopes). CONCLUSIONS Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.
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Affiliation(s)
- Brent K. Hollenbeck
- Center for Healthcare Outcomes and Policy, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
| | - Rodney L. Dunn
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
| | - Anne M. Suskind
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
| | - Yun Zhang
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
| | - John M. Hollingsworth
- Center for Healthcare Outcomes and Policy, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
| | - John D. Birkmeyer
- Department of Urology, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
- Department of Surgery, Bldg 16, First floor, 2800 Plymouth Rd, University of Michigan, Ann Arbor
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Abstract
IMPORTANCE Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. OBJECTIVE To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. DESIGN, SETTING, AND PARTICIPANTS Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. MAIN OUTCOMES AND MEASURES Number of inpatient medical consultations. RESULTS More than half of patients undergoing colectomy (91,684) or THR (339,319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. CONCLUSIONS AND RELEVANCE The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor2VA Ann Arbor Healthcare System, Ann Arbor, Michigan3Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy
| | - Adam S Wilk
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor6VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jyothi R Thumma
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor7Department of Surgery, University of Michigan, Ann Arbor
| | - Mousumi Banerjee
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor8Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
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Miller DC, Birkmeyer JD. Moving Beyond the Headlines: Improving the Technical Quality of Radical Prostatectomy. Eur Urol 2014; 65:1020-2. [DOI: 10.1016/j.eururo.2014.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/05/2014] [Indexed: 11/24/2022]
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Varban OA, Hawasli AA, Carlin AM, Genaw JA, English W, Dimick JB, Wood MH, Birkmeyer JD, Birkmeyer NJO, Finks JF. Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative. Surg Obes Relat Dis 2014; 11:222-8. [PMID: 24981934 DOI: 10.1016/j.soard.2014.04.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 04/01/2014] [Accepted: 04/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162). METHODS Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair. RESULTS Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16). CONCLUSION Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.
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Affiliation(s)
- Oliver A Varban
- Value Partnerships Program, Blue Cross and Blue Shield of Michigan, and the Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Abdelkader A Hawasli
- Department of Surgery, St. John Providence Health System, St. Clair Shores, Michigan
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey A Genaw
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Wayne English
- Department of Surgery, Marquette General Hospital, Marquette, Michigan
| | - Justin B Dimick
- Value Partnerships Program, Blue Cross and Blue Shield of Michigan, and the Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael H Wood
- Department of Surgery, Detroit Medical Center, Detroit, Michigan
| | - John D Birkmeyer
- Value Partnerships Program, Blue Cross and Blue Shield of Michigan, and the Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Nancy J O Birkmeyer
- Value Partnerships Program, Blue Cross and Blue Shield of Michigan, and the Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Value Partnerships Program, Blue Cross and Blue Shield of Michigan, and the Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Sheetz KH, Krell RW, Englesbe MJ, Birkmeyer JD, Campbell DA, Ghaferi AA. The importance of the first complication: understanding failure to rescue after emergent surgery in the elderly. J Am Coll Surg 2014; 219:365-70. [PMID: 25026880 DOI: 10.1016/j.jamcollsurg.2014.02.035] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/08/2014] [Accepted: 02/19/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Perioperative mortality in the elderly is high after emergency surgery and varies considerably among hospitals-an observation partially explained by differences in failure to rescue. We hypothesize that failure to rescue after certain types of complications underlies the disproportionately poor outcomes observed in elderly patients. STUDY DESIGN We identified 23,217 patients undergoing emergent general or vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2007 and 2012. Patients' first complications were identified and categorized by type. We compared failure to rescue rates at the patient-level between patients younger than 75 and 75 years of age and older. We then compared failure to rescue rates after specific complications across hospitals grouped in tertiles by risk-adjusted 30-day mortality. RESULTS Risk-adjusted failure to rescue rates were significantly higher in the elderly after a first infectious (21.7% vs 10.3%; p < 0.01) or pulmonary (38.2% vs 20.4%; p < 0.01) complication when compared with younger patients. At the hospital level, high-mortality centers failed to rescue elderly patients more frequently than low-mortality centers after a first infectious (35.6% vs 22.2%; p < 0.01) and pulmonary (24.3 vs 14.3; p < 0.01) complication. Failure to rescue rates after cardiovascular complications did not differ significantly across patient ages or tertiles of hospital mortality. CONCLUSIONS Hospitals fail to rescue elderly patients at higher rates than younger patients after infectious and pulmonary complications. Efforts to recognize and manage these specific complications have the potential to improve emergency surgical care of the elderly in Michigan.
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Affiliation(s)
- Kyle H Sheetz
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Robert W Krell
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael J Englesbe
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Darrell A Campbell
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
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Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue. JAMA Surg 2014; 149:119-23. [PMID: 24336902 DOI: 10.1001/jamasurg.2013.3649] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. OBJECTIVE To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications. DESIGN, SETTING, AND PARTICIPANTS We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile. EXPOSURE Hospital procedural volume. MAIN OUTCOMES AND MEASURES Hospital rates of risk-adjusted mortality, major complications, and failure to rescue. RESULTS For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred. CONCLUSIONS AND RELEVANCE High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.
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Affiliation(s)
- Andrew A Gonzalez
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago2Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
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Revels SL, Wong SL, Banerjee M, Yin H, Birkmeyer JD. Differences in perioperative care at low- and high-mortality hospitals with cancer surgery. Ann Surg Oncol 2014; 21:2129-35. [PMID: 24710775 DOI: 10.1245/s10434-014-3692-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate adherence to perioperative processes of care associated with major cancer resections. BACKGROUND Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes. METHODS There were 1,279 hospitals participating in the National Cancer DataBase (2005-2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics. RESULTS Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50-0.92 and aRR 0.80, 95 % CI 0.56-0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90-1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81-1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32-0.93). CONCLUSIONS HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.
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Affiliation(s)
- Sha'Shonda L Revels
- Department of Surgery and Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI, USA
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Dimick JB, Birkmeyer NJ, Finks JF, Share DA, English WJ, Carlin AM, Birkmeyer JD. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg 2014; 149:10-6. [PMID: 24132708 DOI: 10.1001/jamasurg.2013.4109] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The optimal approach for profiling hospital performance with bariatric surgery is unclear. OBJECTIVE To develop a novel composite measure for profiling hospital performance with bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS Using clinical registry data from the Michigan Bariatric Surgery Collaborative, we studied all patients undergoing bariatric surgery from January 1, 2008, through December 31, 2010. For laparoscopic gastric bypass surgery, we used empirical Bayes techniques to create a composite measure by combining several measures, including serious complications, reoperations, and readmissions; hospital and surgeon volume; and outcomes with other related procedures. Hospitals were ranked for 2008 through 2009 and placed in 1 of 3 groups: 3-star (top 20%), 2-star (middle 60%), and 1-star (bottom 20%). We assessed how well these ratings predicted outcomes in the next year (2010) compared with other widely used measures. MAIN OUTCOMES AND MEASURES Risk-adjusted serious complications. RESULTS Composite measures explained a larger proportion of hospital-level variation in serious complication rates with laparoscopic gastric bypass than other measures. For example, the composite measure explained 89% of the variation compared with only 28% for risk-adjusted complication rates alone. Composite measures also appeared better at predicting future performance compared with individual measures. When ranked on the composite measure, 1-star hospitals had 2-fold higher serious complication rates (4.6% vs 2.4%; odds ratio, 2.0; 95% CI, 1.1-3.5) compared with 3-star hospitals. Differences in serious complication rates between 1- and 3-star hospitals were much smaller when hospitals were ranked using serious complications (4.0% vs 2.7%; odds ratio, 1.6; 95% CI, 0.8-2.9) and hospital volume (3.3% vs 3.2%; odds ratio, 0.85; 95% CI, 0.4-1.7). CONCLUSIONS AND RELEVANCE Composite measures are much better at explaining hospital-level variation in serious complications and predicting future performance than other approaches. In this preliminary study, it appears that such composite measures may be better than existing alternatives for profiling hospital performance with bariatric surgery.
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Affiliation(s)
- Justin B Dimick
- The Michigan Bariatric Surgery Collaborative (MBSC), University of Michigan, Ann Arbor
| | - Nancy J Birkmeyer
- The Michigan Bariatric Surgery Collaborative (MBSC), University of Michigan, Ann Arbor
| | - Jonathan F Finks
- The Michigan Bariatric Surgery Collaborative (MBSC), University of Michigan, Ann Arbor
| | | | | | | | - John D Birkmeyer
- The Michigan Bariatric Surgery Collaborative (MBSC), University of Michigan, Ann Arbor
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Goodney PP, Travis LL, Brooke BS, DeMartino RR, Goodman DC, Fisher ES, Birkmeyer JD. Relationship between regional spending on vascular care and amputation rate. JAMA Surg 2014; 149:34-42. [PMID: 24258010 DOI: 10.1001/jamasurg.2013.4277] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Although lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear. OBJECTIVE To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral arterial disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 18,463 US Medicare patients who underwent a major peripheral arterial disease-related amputation during the period between 2003 and 2010. EXPOSURE Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions. MAIN OUTCOMES AND MEASURES Correlation coefficient between regional spending on vascular care and regional rates of peripheral arterial disease-related amputation. RESULTS Among patients who ultimately underwent an amputation, 64% were admitted to the hospital in the year prior to the amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including costs related to the amputation procedure itself, was $22,405, but it varied from $11,077 (Bismarck, North Dakota) to $42,613 (Salinas, California) (P < .001). Patients in high-spending regions were more likely to undergo vascular procedures as determined by crude analyses (12.0 procedures per 10,000 patients in the lowest quintile of spending and 20.4 procedures per 10,000 patients in the highest quintile of spending; P < .001) and by risk-adjusted analyses (adjusted odds ratio for receiving a vascular procedure in highest quintile of spending, 3.5 [95% CI, 3.2-3.8]; P < .001). Although revascularization was associated with higher spending (R = 0.38, P < .001), higher spending was not associated with lower regional amputation rates (R = 0.10, P = .06). The regions that were most aggressive in the use of endovascular interventions were the regions that were most likely to have high spending (R = 0.42, P = .002) and high amputation rates (R = 0.40, P = .004). CONCLUSIONS AND RELEVANCE Regions that spend the most on vascular care perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Lori L Travis
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland4Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Benjamin S Brooke
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Randall R DeMartino
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David C Goodman
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Elliott S Fisher
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - John D Birkmeyer
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
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Dimick J, Ruhter J, Sarrazin MV, Birkmeyer JD. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions. Health Aff (Millwood) 2014; 32:1046-53. [PMID: 23733978 DOI: 10.1377/hlthaff.2011.1365] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Research has shown that black patients more frequently undergo surgery at low-quality hospitals than do white patients. We assessed the extent to which living in racially segregated areas and living in geographic proximity to low-quality hospitals contribute to this disparity. Using national Medicare data for all patients who underwent one of three high-risk surgical procedures in 2005-08, we found that black patients actually tended to live closer to higher-quality hospitals than white patients did but were 25-58 percent more likely than whites to receive surgery at low-quality hospitals. Racial segregation was also a factor, with black patients in the most segregrated areas 41-96 percent more likely than white patients to undergo surgery at low-quality hospitals. To address these disparities, care navigators and public reporting of comparative quality could steer patients and their referring physicians to higher-quality hospitals, while quality improvement efforts could focus on improving outcomes for high-risk surgery at hospitals that disproportionately serve black patients. Unfortunately, existing policies such as pay-for-performance, bundled payments, and nonpayment for adverse events may divert resources and exacerbate these disparities.
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Affiliation(s)
- Justin Dimick
- Division of Minimally Invasive Surgery, University of Michigan, Ann Arbor, Michigan, USA.
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Hollingsworth JM, Birkmeyer JD, Ye Z, Miller DC. Specialty-specific trends in the prevalence and distribution of outpatient surgery: implications for payment and delivery system reforms. Surg Innov 2014; 21:560-5. [PMID: 24608183 DOI: 10.1177/1553350613520515] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND With nearly 53 million ambulatory procedures performed annually, future efforts to achieve greater value in surgical care should include a focus on outpatient surgery. To inform such efforts, a better understanding of specialty-specific trends in outpatient surgery is required. OBJECTIVES To assess the prevalence and distribution of outpatient surgery across specialties. RESEARCH DESIGN Repeated cross-sectional. MEASURES Using all-payer data from Florida (1998-2008), we identified physicians who performed one or more procedures. We assigned a specialty to each physician based on his procedure mix. After measuring the proportion of procedures performed on an outpatient basis, we assessed for specialty-specific changes over time in this proportion. Finally, we determined the frequency with which individual specialties used surgery centers for their outpatient care. RESULTS More than two thirds (67.8%) of all surgical procedures are carried out on an outpatient basis. The popularity of outpatient surgery has grown among many specialties over the past decade, including several (urology, gastroenterology, plastic surgery, and ophthalmology) that perform most of their cases in outpatient settings. Within surgical disciplines, overall trends in the use of outpatient surgery are strongly associated with the specialty's affinity for freestanding ambulatory surgery centers (Pearson's correlation coefficient = 0.76; P < .001). CONCLUSIONS A majority of surgeons in many specialties now provide predominantly outpatient care. Incorporating these findings into the design of future payment and delivery system reforms will help ensure adequate surgeon exposure to the efficiency gains that evolve from them.
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Affiliation(s)
| | | | - Zaojun Ye
- University of Michigan, Ann Arbor, MI, USA
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Veroff DR, Birkmeyer JD, Wennberg DE. Patient-physician shared decision making. JAMA 2014; 311:863. [PMID: 24570255 DOI: 10.1001/jama.2013.285157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - David E Wennberg
- Northern New England Accountable Care Collaborative, Portland, Maine
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Krell RW, Birkmeyer NJO, Reames BN, Carlin AM, Birkmeyer JD, Finks JF. Effects of resident involvement on complication rates after laparoscopic gastric bypass. J Am Coll Surg 2013; 218:253-60. [PMID: 24315885 DOI: 10.1016/j.jamcollsurg.2013.10.014] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/09/2013] [Accepted: 10/16/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although resident involvement has been shown to be safe for most procedures, the impact of residents on outcomes after complex laparoscopic procedures is not well understood. We sought to examine the impact of resident involvement on outcomes after bariatric surgery using a population-based clinical registry. STUDY DESIGN We analyzed 17,057 patients who underwent a primary laparoscopic gastric bypass in the 35-hospital Michigan Bariatric Surgery Collaborative from July 2006 to August 2012. Resident involvement was characterized at the surgeon level. Using hierarchical logistic regression, we examined the influence of resident involvement on 30-day complications, accounting for patient characteristics as well as hospital and surgeon case volume. To evaluate potential mediating factors for specific complications, we also adjusted for operative duration. RESULTS Risk-adjusted 30-day complication rates with and without residents were 13.0% and 8.5%, respectively (p < 0.01). Resident involvement was independently associated with wound infection (odds ratio [OR] = 2.06; 95% CI, 1.24-3.43) and venous thromboembolism (OR = 2.01; 95% CI, 1.19-3.40), but not with any other medical or surgical complications. Operative duration was longer with resident involvement (median duration with residents 129 minutes vs 88 minutes without; p < 0.01). After adjusting for operative duration, resident involvement was still independently associated with wound infection (OR = 1.67; 95% CI, 1.01-2.76), but not venous thromboembolism (OR = 1.73; 95% CI, 0.99-3.04). CONCLUSIONS Resident involvement in laparoscopic gastric bypass is independently associated with wound infections and venous thromboembolism. The effect appears to be mediated in part by longer operative times. These findings highlight the importance of strategies to assess and improve resident technical proficiency outside the operating room.
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Affiliation(s)
- Robert W Krell
- Center for Healthcare Outcomes and Policy, University of Michigan Health System, Ann Arbor, MI.
| | - Nancy J O Birkmeyer
- Center for Healthcare Outcomes and Policy, University of Michigan Health System, Ann Arbor, MI
| | - Bradley N Reames
- Center for Healthcare Outcomes and Policy, University of Michigan Health System, Ann Arbor, MI
| | | | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, University of Michigan Health System, Ann Arbor, MI
| | - Jonathan F Finks
- Center for Healthcare Outcomes and Policy, University of Michigan Health System, Ann Arbor, MI
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Birkmeyer JD, Finks JF, O'Reilly A, Oerline M, Carlin AM, Nunn AR, Dimick J, Banerjee M, Birkmeyer NJO. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013; 369:1434-42. [PMID: 24106936 DOI: 10.1056/nejmsa1300625] [Citation(s) in RCA: 949] [Impact Index Per Article: 86.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes. METHODS We conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients. RESULTS Mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, as compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01). The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes, P<0.001) and higher rates of reoperation (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001). CONCLUSIONS The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency.
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Affiliation(s)
- John D Birkmeyer
- Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Abstract
Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.
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Affiliation(s)
- Peter McCulloch
- Nuffield Department of Surgical Science, University of Oxford, Oxford, UK.
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Abstract
The use of common surgical procedures varies widely across regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain only a small degree of regional variation in surgery rates. Evidence suggests that surgical variation results mainly from differences in physician beliefs about the indications for surgery, and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help to explain the so-called surgical signatures of specific procedures, and why some consistently vary more than others. Variation in clinical decision making is, in turn, affected by broad environmental factors, including technology diffusion, supply of specialists, local training frameworks, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions could help to mitigate regional variation, but broader dissemination of shared decision aids will be essential to reduce variation in preference-sensitive disorders.
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Affiliation(s)
- John D Birkmeyer
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA.
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Kocher KE, Nallamothu BK, Birkmeyer JD, Dimick JB. Emergency Department Visits After Surgery Are Common For Medicare Patients, Suggesting Opportunities To Improve Care. Health Aff (Millwood) 2013; 32:1600-7. [DOI: 10.1377/hlthaff.2013.0067] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Keith E. Kocher
- Keith E. Kocher ( ) is an assistant professor of emergency medicine in the Department of Emergency Medicine, University of Michigan, in Ann Arbor
| | - Brahmajee K. Nallamothu
- Brahmajee K. Nallamothu is an associate professor of internal medicine in the Division of Cardiovascular Medicine, University of Michigan
| | - John D. Birkmeyer
- John D. Birkmeyer is a professor of surgery in the Department of Surgery, University of Michigan
| | - Justin B. Dimick
- Justin B. Dimick is an associate professor of surgery in the Department of Surgery, University of Michigan
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Abstract
IMPORTANCE Much of the enthusiasm for accountable care organizations is fueled by evidence that integrated delivery systems (IDSs) perform better on measures of quality and cost in the ambulatory care setting; however, the benefits of this model are less clear for complex hospital-based care. OBJECTIVE To assess whether existing IDSs are associated with improved quality and lower costs for episodes of inpatient surgery. DESIGN, SETTING, AND PATIENTS We used national Medicare data (January 1, 2005, through November 30, 2007) to compare the quality and cost of inpatient surgery among patients undergoing coronary artery bypass grafting, hip replacement, back surgery, or colectomy in IDS-affiliated hospitals compared with those treated in a matched group of non-IDS-affiliated centers. MAIN OUTCOME MEASURES Operative mortality, postoperative complications, readmissions, and total and component surgical episode costs. RESULTS Patients treated in IDS hospitals differed according to several characteristics, including race, admission acuity, and comorbidity. For each of the 4 procedures, adjusted rates for operative mortality, complications, and readmissions were similar for patients treated in IDS-affiliated compared with non-IDS-affiliated hospitals, with the exception that those treated in IDS-affiliated hospitals had fewer readmissions after colectomy (12.6% vs 13.5%, P = .03). Adjusted total episode payments for hip replacement were 4% lower in IDS-affiliated hospitals (P < .001), with this difference explained mainly by lower expenditures for postdischarge care. Episode payments differed by 1% or less for the remaining procedures. CONCLUSIONS The benefits of the IDSs observed for ambulatory care may not extend to inpatient surgery. Thus, improvements in the quality and cost-efficiency of hospital-based care may require adjuncts to current ACO programs.
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Affiliation(s)
- David C Miller
- Department of Urology, University of Michigan, North Campus Research Complex, Ann Arbor, MI 48109, USA.
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Goodney PP, Holman K, Henke PK, Travis LL, Dimick JB, Stukel TA, Fisher ES, Birkmeyer JD. Regional intensity of vascular care and lower extremity amputation rates. J Vasc Surg 2013; 57:1471-79, 1480.e1-3; discussion 1479-80. [PMID: 23375611 PMCID: PMC3660510 DOI: 10.1016/j.jvs.2012.11.068] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 11/16/2012] [Accepted: 11/16/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Because patient-level differences do not fully explain the variation in lower extremity amputation rates across the United States, we hypothesized that variation in intensity of vascular care may also affect regional rates of amputation and examined the relationship between the intensity of vascular care and the population-based rate of major lower extremity amputation (above-knee or below-knee) from vascular disease. METHODS Intensity of vascular care was defined as the proportion of Medicare patients who underwent any vascular procedure in the year before amputation, calculated at the regional level (2003 to 2006), using the 306 hospital referral regions in the Dartmouth Atlas of Healthcare. The relationship between intensity of vascular care and major amputation rate, at the regional level, was examined between 2007 and 2009. RESULTS Amputation rates varied widely by region, from one to 27 per 10,000 Medicare patients. Compared with regions in the lowest quintile of amputation rate, patients in the highest quintile were commonly African American (50% vs 13%) and diabetic (38% vs 31%). Intensity of vascular care also varied across regions: <35% of patients underwent revascularization in the lowest quintile of intensity, whereas nearly 60% underwent revascularization in the highest quintile. Overall, an inverse correlation was found between intensity of vascular care and the amputation rate, ranging from R = -0.36 for outpatient diagnostic and therapeutic procedures to R = -0.87 for inpatient surgical revascularizations. Analyses adjusting for patient characteristics and socioeconomic status found patients in high-intensity vascular care regions were significantly less likely to undergo amputation without an antecedent attempt at revascularization (odds ratio, 0.37; 95% confidence interval, 0.34-0.37; P < .001). CONCLUSIONS The intensity of vascular care provided to patients at risk for amputation varies, and regions with the most intensive vascular care have the lowest amputation rate, although the observational nature of these associations do not impart causality. High-risk patients, especially African American diabetic patients residing in low-intensity vascular care regions, represent an important target for systematic efforts to reduce amputation risk.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
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Birkmeyer NJ, Finks JF, English WJ, Carlin AM, Hawasli AA, Genaw JA, Wood MH, Share DA, Birkmeyer JD. Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery. J Hosp Med 2013; 8:173-7. [PMID: 23401464 DOI: 10.1002/jhm.2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/18/2012] [Accepted: 12/23/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND The United States Food and Drug Administration recently issued a warning about adverse events in patients receiving inferior vena cava (IVC) filters. OBJECTIVE To assess relationships between IVC filter insertion and complications while controlling for differences in baseline patient characteristics and medical venous thromboembolism prophylaxis. DESIGN Propensity-matched cohort study. SETTING The prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. PATIENTS Bariatric surgery patients (n=35,477) from 32 hospitals during the years 2006 through 2012. INTERVENTION Prophylactic IVC filter insertion. MEASUREMENTS Outcomes included the occurrence of complications (pulmonary embolism, deep vein thrombosis, and overall combined rates of complications by severity) within 30 days of bariatric surgery. RESULTS There were no significant differences in baseline characteristics among the 1,077 patients with IVC filters and in 1,077 matched control patients. Patients receiving IVC filters had higher rates of pulmonary embolism (0.84% vs 0.46%; odds ratio [OR], 2.0; 95% confidence interval [CI], 0.6-6.5; P=0.232), deep vein thrombosis (1.2% vs 0.37%; OR, 3.3; 95% CI, 1.1-10.1; P=0.039), venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1-6.3, P=0.027), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0-2.4; P=0.031), permanently disabling complications (1.2% vs 0.37%; OR, 4.3; 95% CI, 1.2-15.6; P=0.028), and death (0.7% vs 0.09%; OR, 7.0; 95% CI, 0.9-57.3; P=0.068). Of the 7 deaths among patients with IVC filters, 4 were attributable to pulmonary embolism and 2 to IVC thrombosis/occlusion. CONCLUSIONS We have identified no benefits and significant risks to the use of prophylactic IVC filters among bariatric surgery patients and believe that their use should be discouraged.
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Affiliation(s)
- Nancy J Birkmeyer
- Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Chen LM, Birkmeyer JD, Saint S, Jha AK. Hospitalist staffing and patient satisfaction in the national Medicare population. J Hosp Med 2013; 8:126-31. [PMID: 23288691 PMCID: PMC3663143 DOI: 10.1002/jhm.2001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 10/26/2012] [Accepted: 11/14/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Payers are increasingly holding hospitals accountable for patients' experiences with their care. This may conflict with another trend among US hospitals-greater hospitalist care-as hospitalists may have less familiarity with the history and preferences of their patients compared with primary-care physicians. OBJECTIVE Our objective was to better understand the relationship between hospitalist care and patients' experiences with their care. DESIGN This was a retrospective cohort study. SETTING The setting was 2843 US acute-care hospitals (bottom tertile or "non-hospitalist" hospitals: median of 0% of general-medicine patients cared for by hospitalists; middle tertile or "mixed" hospitals: median of 39.5%; top tertile or "hospitalist" hospitals: median of 76.5%). PATIENTS The patients were 132,814 hospitalized Medicare beneficiaries cared for by a general medicine physician in 2009. MEASUREMENTS The measurements were hospitalist use, based on Medicare claims data, and patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey. RESULTS "Hospitalist" hospitals had better performance on global measures of patient satisfaction than "mixed" or "non-hospitalist" hospitals (overall satisfaction: 65.6% vs 63.9% vs 63.9%, respectively, P value for difference < 0.001). Hospitalist hospitals performed better in 6 specific domains of care, with the largest difference in satisfaction with discharge compared with mixed or non-hospitalist hospitals (80.3% vs 79.1% vs 78.1%, P < 0.001). Hospitalist care was not associated with patient satisfaction in 2 domains of care: cleanliness of room and communication with physician. CONCLUSION For most measures of patient satisfaction, greater hospitalist care was associated with modestly better patient-centered care.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 2013; 309:792-9. [PMID: 23443442 PMCID: PMC3785293 DOI: 10.1001/jama.2013.755] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. OBJECTIVE To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. DESIGN, SETTING, AND PATIENTS Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy). MAIN OUTCOME MEASURES Risk-adjusted rates of any complication, serious complications, and reoperation. RESULTS Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). CONCLUSIONS AND RELEVANCE Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.
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Affiliation(s)
- Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA.
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Birkmeyer JD. Edward E. Mason lecture: Strategies for improving the quality of bariatric surgery. Surg Obes Relat Dis 2013; 9:604-8. [PMID: 23295163 DOI: 10.1016/j.soard.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- John D Birkmeyer
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michingan.
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