Guideline-discordant care among females undergoing groin hernia repair: the importance of sex as a biologic variable.

PURPOSE: Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable. METHODS: Retrospective cohort study of adults undergoing elective groin hernia repair (2014-2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys. RESULTS: Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%, p < 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80-0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%, p = 0.003). CONCLUSIONS: Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population.

Importance of teamwork, communication and culture on failure-to-rescue in the elderly.

BACKGROUND: Surgical mortality increases significantly with age. Wide variations in mortality rates across hospitals suggest potential levers for improvement. Failure-to-rescue has been posited as a potential mechanism underlying these differences. METHODS: A review was undertaken of the literature evaluating surgery, mortality, failure-to-rescue and the elderly. This was followed by a review of ongoing studies and unpublished work aiming to understand better the mechanisms underlying variations in surgical mortality in elderly patients. RESULTS: Multiple hospital macro-system factors, such as nurse staffing, available hospital technology and teaching status, are associated with differences in failure-to-rescue rates. There is emerging literature regarding important micro-system factors associated with failure-to-rescue. These are grouped into three broad categories: hospital resources, attitudes and behaviours. Ongoing work to produce interventions to reduce variations in failure-to-rescue rates include a focus on teamwork, communication and safety culture. Researchers are using novel mixed-methods approaches and theories adapted from organizational studies in high-reliability organizations in an effort to improve the care of elderly surgical patients. CONCLUSION: Although elderly surgical patients experience failure-to-rescue events at much higher rates than their younger counterparts, patient-level effects do not sufficiently explain these differences. Increased attention to the role of organizational dynamics in hospitals' ability to rescue these high-risk patients will establish high-yield interventions aimed at improving patient safety.

Case mix, quality and high-cost kidney transplant patients.

A better understanding of high-cost kidney transplant patients would be useful for informing value-based purchasing strategies by payers. This retrospective cohort study was based on the Medicare Provider Analysis and Review (MEDPAR) files from 2003 to 2006. The focus of this analysis was high-cost kidney transplant patients (patients that qualified for Medicare outlier payments and 30-day readmission payments). Using regression techniques, we explored relationships between high-cost kidney transplant patients, center-specific case mix, and center quality. Among 43 393 kidney transplants in Medicare recipients, 35.2% were categorized as high-cost patients. These payments represented 20% of total Medicare payments for kidney transplantation and exceeded $200 million over the study period. Case mix was associated with these payments and was an important factor underlying variation in hospital payments high-cost patients. Hospital quality was also a strong determinant of future Medicare payments for high-cost patients. Compared to high-quality centers, low-quality centers cost Medicare an additional $1185 per kidney transplant. Payments for high-cost patients represent a significant proportion of the total costs of kidney transplant surgical care. Quality improvement may be an important strategy for reducing the costs of kidney transplantation.

Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy.

BACKGROUND: Nurse-to-patient ratios in the intensive care unit are associated with postoperative mortality, morbidity, and costs after some high-risk surgery. OBJECTIVE: To determine if having 1 nurse caring for 1 or 2 patients ("more nurses") versus 1 nurse caring for 3 or more patients ("fewer nurses") in the intensive care unit at night is associated with differences in clinical and economic outcomes after hepatectomy. METHODS: Statewide observational cohort study of 569 adults who had hepatic resection, 1994 to 1998. Hospital discharge data were linked to a prospective survey of organizational characteristics in the intensive care unit. Multivariate analysis was used to determine the association of nighttime nurse-to-patient ratios with in-hospital mortality, length of stay, hospital costs, and specific postoperative complications. RESULTS: A total of 240 patients at 25 hospitals had fewer nurses; 316 patients in 8 hospitals had more nurses. No significant association between nighttime nurse-to-patient ratios and in-hospital mortality was detected. The overall complication rate was 28%. By univariate analysis, patients with fewer nurses had increased risks for pulmonary failure (5.8% vs 1.6%, relative risk, 3.6; 95% CI, 1.3-10.1; P=.006) and reintubation (10.8% vs 1.9%, relative risk, 5.7; 95% CI, 2.4-13.7; P<.001). By multivariate analysis, patients with fewer nurses had increased risk for reintubation (odds ratio, 2.9; 95% CI, 1.0-8.1; P=.04) and a 14% increase (95% CI, 3%-23%; P=.007) or an additional $1248 (95% CI, $384-$2112; P = .005) in total hospital costs. CONCLUSIONS: Fewer nurses at night is associated with increased risk for specific postoperative pulmonary complications and with increased resource use in patients undergoing hepatectomy.

Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland.

BACKGROUND: Previous studies have documented a relationship between hospital volume and perioperative and economic outcomes. Our objective was to determine the effect of hospital volume on outcomes of esophageal resection. METHODS: Statewide database was analyzed for patients who underwent esophageal resection in Maryland (n = 1,136 patients) from 1984 to 1999. Multivariate regression was used to determine the association of hospital volume with in-hospital mortality, length of stay, and charges after adjusting for case mix and time period. RESULTS: Unadjusted in-hospital mortality rates were lower in high volume hospitals (2.7%) than medium (12.7%) and low (16%) volume hospitals (p < 0.001). High hospital volume was associated with (1) fivefold reduction in the risk of death (odds ratio, 0.21; 95% confidence interval, 0.10 to 0.42; p < 0.001); (2) a 6-day (95% confidence interval, 5 to 7 days; p < 0.001) reduction in length of stay; and (3) $11,673 (95% confidence interval, $9,504 to $12,841; p < 0.001) decrease in hospital charges. Conclusions. Hospitals that perform high volumes of esophageal resection have superior clinical and economic outcomes. By referring these patients to high volume centers, we may improve quality and reduce costs.

Negative results of randomized clinical trials published in the surgical literature: equivalency or error?

HYPOTHESIS: We hypothesized that review of randomized controlled clinical trials (RCTs) with nonstatistically significant or "negative" results published in the surgical literature do not have appropriate statistical power to demonstrate equivalency between treatment arms. DATA SOURCES AND STUDY SELECTION: The MEDLINE database was searched to obtain reports of all RCTs with negative results published in 3 surgical journals from 1988 to 1998. Manual review of one year (1997) of publications for each journal was performed to validate our search strategy. Equivalency was evaluated using the Two One-Sided Tests Procedure and post hoc power calculations. DATA SYNTHESIS: Ninety reports of RCTs with negative results were identified in the surgical literature between 1988 and 1998. The manual review of 1997 showed a 100% retrieval rate for our search strategy. After applying the Two One-Sided Tests Procedure, 35 reports (39%) met the criteria for demonstrating equivalency. The other 55 reports (61%) contained at least a 10% absolute difference in the 90% confidence interval of Delta. Using the power calculation method, only 22 (24%) articles had a power greater than.80 to detect a 50% difference in therapeutic effect. Only 29% of the reports included a formal sample size calculation and these studies were more likely to demonstrate equivalency than those without a sample size estimate (P<.01). CONCLUSIONS: Many reports from negative RCTs published in the surgical literature lack sufficient statistical power to establish that clinically important differences are not present. Surgeons should perform appropriate sample size calculations when designing RCTs and recognize the utility of confidence intervals when reporting negative results.

Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection.

OBJECTIVE: To determine whether having daily rounds by an intensive care unit (ICU) physician is associated with clinical and economic outcomes after esophageal resection. DESIGN: ICU information was obtained from a prospective survey and linked to retrospective patient data from the Maryland Health Services Cost Review Commission. The main outcome variables were in-hospital mortality rate, length of stay, hospital cost, and complications after esophageal resection. SETTING: Nonfederal acute care hospitals in Maryland that performed esophageal resection (n = 35 hospitals) during the study period, 1994-1998. PATIENTS: Adult patients who underwent esophageal resection in Maryland (n = 366 patients) from 1994 to 1998. INTERVENTIONS: Presence vs. absence of daily rounds by an ICU physician. MEASUREMENTS AND MAIN RESULTS: After adjusting for patient case-mix and other hospital characteristics, lack of daily rounds by an ICU physician was independently associated with a 73% increase in hospital length of stay (7 days; 95% confidence interval [CI], 1-15; p =.012) and a 61% increase in total hospital cost ($8,839; 95% CI, $ 1,674-$19,192; p =.013), but there was no association with in-hospital mortality rate. In addition, the following postoperative complications were independently associated with lack of daily rounds by an ICU physician: pulmonary insufficiency (odds ratio [OR], 4.0; CI, 1.4-11.0), renal failure (OR, 6.3; CI, 1.4-28.7), aspiration (OR, 1.7; CI, 1.0-2.8), and reintubation (OR, 2.8; CI, 1.5-5.2). CONCLUSIONS: Having daily rounds by an ICU physician is associated with shorter lengths of stay, lower hospital cost, and decreased frequency of postoperative complications after esophageal resection. Healthcare providers and policymakers should use this information to help improve quality of care and reduce costs for patients undergoing high-risk surgical procedures.

Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit.

HYPOTHESIS: Catheter-related bloodstream infection (CRBSI) in critically ill surgical patients with prolonged intensive care unit (ICU) stays is associated with a significant increase in health care resource use. DESIGN: Prospective cohort study. SETTING: Surgical ICU at a large tertiary care center. PATIENTS: Critically ill surgical patients (N = 260) with projected surgical ICU length of stay greater than 3 days. INTERVENTIONS: Central venous catheters were cultured for clinical suspicion of infection. MAIN OUTCOME MEASURES: Increases in total hospital cost, ICU cost, hospital days, and ICU days attributable to CRBSI were estimated using multiple linear regression after adjusting for demographic factors and severity of illness (APACHE III [Apache Physiology and Chronic Health Evaluation III] score). RESULTS: The incidence of CRBSI per 1000 catheter-days was 3.6 episodes (95% confidence interval [CI], 2.1-5.8 episodes). Microbiologic isolates were Gram-positive bacteria in 75%, Gram-negative bacteria in 20%, and yeast in 5%. After adjusting for demographic factors and severity of disease, CRBSI was associated with an increase of $56 167 (95% CI, $11 523-$165 735; P =.001) (in 1998 dollars) in total hospital cost, an increase of $71 443 (95% CI, $11 960-$195 628; P<.001) in ICU cost, a 22-day increase in hospital length of stay, and a 20-day increase in ICU length of stay. CONCLUSIONS: For critically ill surgical patients, CRBSI is associated with a profound increase in resource use. Prevention, early diagnosis, and intervention for CRBSI might result in cost savings in this high-risk population.

ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy.

OBJECTIVE: To determine if having a night-time nurse-to-patient ratio (NNPR) of one nurse caring for one or two patients (> 1:2) versus one nurse caring for three or more patients (< 1:2) in the intensive care unit (ICU) is associated with clinical and economic outcomes following esophageal resection. DESIGN: State-wide observational cohort study. Hospital discharge data was linked to a prospective survey of ICU organizational characteristics. Multivariate analysis adjusting for case-mix, hospital and surgeon volume was used to determine the association of NNPR with in-hospital mortality, length of stay (LOS), hospital cost and specific postoperative complications. SETTING: Non-federal acute care hospitals (n = 35) in Maryland that performed esophageal resection. PATIENTS AND PARTICIPANTS: Adult patients who had esophageal resection in Maryland, 1994 to 1998 (n = 366 patients). MEASUREMENTS AND RESULTS: Two hundred twenty-five patients at nine hospitals had a NNPR > 1:2;128 patients in 23 hospitals had a NNPR < 1:2. No significant association between NNPR and in-hospital mortality was seen. A 39 % increase in median in-hospital LOS (4.3 days; 95% CI, (2, 5 days); p < 0.001), and a 32% increase in costs ($4,810; 95 % CI, ($2,094, $7,952) was associated with a NNPR < 1:2. Pneumonia (OR 2.4; 95 % CI (1.2, 4.7); p = 0.012), reintubation (OR 2.6; 95% CI(1.4, 4.5);p = 0.001), and septicemia (OR 3.6; 95 % CI(1.1, 12.5); p = 0.04), were specific complications associated with a NNPR < 1:2. CONCLUSIONS: A nurse caring for more than two ICU patients at night increases the risk of several postoperative pulmonary and infectious complications and was associated with increased resource use in patients undergoing esophageal resection.