Exposure to Operative Anesthesia in Childhood and Subsequent Neurobehavioral Diagnoses: A Natural Experiment using Appendectomy.

BACKGROUND: Observational studies of anesthetic neurotoxicity may be biased because children requiring anesthesia commonly have medical conditions associated with neurobehavioral problems. This study takes advantage of a natural experiment associated with appendicitis, in order to determine if anesthesia and surgery in childhood were specifically associated with subsequent neurobehavioral outcomes. METHODS: We identified 134,388 healthy children with appendectomy and examined the incidence of subsequent externalizing or behavioral disorders (conduct, impulse control, oppositional defiant, or attention-deficit/hyperactivity disorder); or internalizing or mood/anxiety disorders (depression, anxiety, or bipolar disorder) when compared to 671,940 matched healthy controls as identified in Medicaid data between 2001-2018. For comparison, we also examined 154,887 otherwise healthy children admitted to the hospital for pneumonia, cellulitis, and gastroenteritis, of which only 8% received anesthesia, and compared them to 774,435 matched healthy controls. We also examined the difference-in-differences between matched appendectomy patients and their controls and matched medical admission patients and their controls. RESULTS: Compared to controls, children with appendectomy were more likely to have subsequent behavioral disorders (the hazard ratio (HR) was 1.04 (95% CI 1.01, 1.06), P = 0.0010), and mood/anxiety disorders (HR: 1.15 (95% CI 1.13, 1.17), P < 0.0001). Relative to controls, children with medical admissions were also more likely to have subsequent behavioral (HR: 1.20 (95% CI 1.18, 1.22), P < 0.0001), and mood/anxiety (HR: 1.25 (95% CI 1.23, 1.27), P < 0.0001) disorders. Comparing the difference between matched appendectomy patients and their matched controls to the difference between matched medical patients and their matched controls, medical patients had more subsequent neurobehavioral problems than appendectomy patients. CONCLUSIONS: Although there is an association between neurobehavioral diagnoses and appendectomy, this association is not specific to anesthesia exposure, and is stronger in medical admissions. Medical admissions, generally without anesthesia exposure, displayed significantly higher rates of these disorders than appendectomy-exposed patients.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes.

OBJECTIVE: To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA: It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS: Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS: We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS: Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Assessing the Ambulatory Surgery Center Volume-Outcome Association.

Importance: In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective: To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants: This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures: Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results: Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance: In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates.

BACKGROUND: We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region. OBJECTIVE: To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region. DESIGN: A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals. MAIN MEASURES: 30-day (primary) and 90-day (secondary) all-cause mortality. KEY RESULTS: 30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality. LIMITATIONS: The study used claims-based data. CONCLUSIONS: In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

Redefining Multimorbidity in Older Surgical Patients.

BACKGROUND: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations. STUDY DESIGN: We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching. RESULTS: Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795). CONCLUSIONS: Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity.

BACKGROUND: Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased. OBJECTIVE: To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs. RESEARCH DESIGN: Matched cohort study. SUBJECTS: Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures. MEASURES: Seven and 30-day revisit and complication rates. RESULTS: For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately. CONCLUSIONS: The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.

Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions.

BACKGROUND: The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers. OBJECTIVE: Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions. DESIGN: Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia. MAIN MEASURES: Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001). CONCLUSION: The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.

Alzheimer's Dementia After Exposure to Anesthesia and Surgery in the Elderly: A Matched Natural Experiment Using Appendicitis.

OBJECTIVE: The aim of this study was to determine whether surgery and anesthesia in the elderly may promote Alzheimer disease and related dementias (ADRD). BACKGROUND: There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations. METHODS: A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the ''Appendectomy'' treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD. RESULTS: The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 [95% confidence interval (CI) 0.94-0.98], P < 0.0001, (28.2% in Appendectomy vs 29.1% in controls, at 7.5 years). The HR for death was 0.97 (95% CI 0.95-0.99), P = 0.002, (22.7% vs 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (95% CI 0.86-0.92), P < 0.0001, (7.6% in Appendectomy vs 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group. CONCLUSION: In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.

Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients.

BACKGROUND: There are known clinical benefits associated with investments in nursing. Less is known about their value. AIMS: To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks. METHODS: Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors. RESULTS: Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources. CONCLUSION: Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

A National Comparison of Operative Outcomes of New and Experienced Surgeons.

OBJECTIVE: To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity. BACKGROUND: Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood. METHODS: A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined. RESULTS: In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)). CONCLUSIONS: Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions.

BACKGROUND: Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. OBJECTIVE: To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. DESIGN: Matched cohort study of patients in 306 acute care hospitals. PATIENTS: A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. MAIN MEASURES: Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. KEY RESULTS: Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost. CONCLUSIONS: Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

Using Medicare claims in identifying Alzheimer's disease and related dementias.

INTRODUCTION: This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims. METHODS: Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity. RESULTS: We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD. DISCUSSION: Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis.

OBJECTIVE: To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics. BACKGROUND: Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear. METHODS: A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery. RESULTS: In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals. CONCLUSIONS: Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis.

BACKGROUND: Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear. OBJECTIVE: Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics. DESIGN: Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05). PARTICIPANTS: Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA). EXPOSURE: Treatment at major teaching hospitals versus non-teaching hospitals. MAIN MEASURES: Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival. KEY RESULTS: Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results. CONCLUSIONS AND RELEVANCE: Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons.

OBJECTIVE: The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA: In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS: We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS: Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS: Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules.

BACKGROUND: Concern persists that extended shifts in medical residency programs may adversely affect patient safety. METHODS: We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures. RESULTS: The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings. CONCLUSIONS: Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Disparities in Breast Cancer Survival by Socioeconomic Status Despite Medicare and Medicaid Insurance.

Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance. CONTEXT: Disparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations. METHODS: We conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors. MEASUREMENTS: 5-year and median survival. FINDINGS: LSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls. CONCLUSIONS: In Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Defining Multimorbidity in Older Surgical Patients.

BACKGROUND: There are numerous definitions of multimorbidity (MM). None systematically examines specific comorbidity combinations accounting for multiple testing when exploring large datasets. OBJECTIVES: Develop and validate a list of all single, double, and triple comorbidity combinations, with each individual qualifying comorbidity set (QCS) more than doubling the odds of mortality versus its reference population. Patients with at least 1 QCS were defined as having MM. RESEARCH DESIGN: Cohort-based study with a matching validation study. SUBJECTS: All fee-for-service Medicare patients between age 65 and 85 without dementia or metastatic solid tumors undergoing general surgery in 2009-2010, and an additional 2011-2013 dataset. MEASURES: 30-day all-location mortality. RESULTS: There were 576 QCSs (2 singles, 63 doubles, and 511 triples), each set more than doubling the odds of dying. In 2011, 36% of eligible patients had MM. As a group, multimorbid patients (mortality rate=7.0%) had a mortality Mantel-Haenszel odds ratio=1.90 (1.77-2.04) versus a reference that included both multimorbid and nonmultimorbid patients (mortality rate=3.3%), and Mantel-Haenszel odds ratio=3.72 (3.51-3.94) versus only nonmultimorbid patients (mortality rate=1.6%). When matching 3151 pairs of multimorbid patients from low-volume hospitals to similar patients in high-volume hospitals, the mortality rates were 6.7% versus 5.2%, respectively (P=0.006). CONCLUSIONS: A list of QCSs identified a third of older patients undergoing general surgery that had greatly elevated mortality. These sets can be used to identify vulnerable patients and the specific combinations of comorbidities that make them susceptible to poor outcomes.

Adjustment for Atherosclerosis Diagnosis Distorts the Effects of Percutaneous Coronary Intervention and the Ranking of Hospital Performance.

BACKGROUND: Coronary atherosclerosis raises the risk of acute myocardial infarction (AMI), and is usually included in AMI risk-adjustment models. Percutaneous coronary intervention (PCI) does not cause atherosclerosis, but may contribute to the notation of atherosclerosis in administrative claims. We investigated how adjustment for atherosclerosis affects rankings of hospitals that perform PCI. METHODS AND RESULTS: This was a retrospective cohort study of 414 715 Medicare beneficiaries hospitalized for AMI between 2009 and 2011. The outcome was 30-day mortality. Regression models determined the association between patient characteristics and mortality. Rankings of the 100 largest PCI and non-PCI hospitals were assessed with and without atherosclerosis adjustment. Patients admitted to PCI hospitals or receiving interventional cardiology more frequently had an atherosclerosis diagnosis. In adjustment models, atherosclerosis was associated, implausibly, with a 42% reduction in odds of mortality (odds ratio=0.58, P<0.0001). Without adjustment for atherosclerosis, the number of expected lives saved by PCI hospitals increased by 62% (P<0.001). Hospital rankings also changed: 72 of the 100 largest PCI hospitals had better ranks without atherosclerosis adjustment, while 77 of the largest non-PCI hospitals had worse ranks (P<0.001). CONCLUSIONS: Atherosclerosis is almost always noted in patients with AMI who undergo interventional cardiology but less often in medically managed patients, so adjustment for its notation likely removes part of the effect of interventional treatment. Therefore, hospitals performing more extensive imaging and more PCIs have higher atherosclerosis diagnosis rates, making their patients appear healthier and artificially reducing the expected mortality rate against which they are benchmarked. Thus, atherosclerosis adjustment is detrimental to hospitals providing more thorough AMI care.