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1.
J Patient Saf ; 17(5): e440-e447, 2021 08 01.
Article in English | MEDLINE | ID: mdl-28234727

ABSTRACT

OBJECTIVE: The aims of the study were to develop risk-adjusted models and apply them for comparisons of hospital performance to define potentially preventable adverse outcomes (OAs) in Medicare lung resection surgery. METHODS: The Medicare Limited Data Set for 2010-2012 was used to design predictive risk models for the four OAs of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without hospital readmission, and 90-day readmissions after removal of unrelated readmission events. The probability of adverse events for each hospital was used to compute the hospital-specific standard deviation (SD) tailored to patient risk profiles. Observed versus predicted adverse events divided by the hospital-specific SD identified the z score for each hospital. Risk-adjusted OA rates were then computed for comparing hospital performance. RESULTS: A total of 39,405 lung resection patients from 739 hospitals had 768 inpatient deaths (1.9%), 3147 had prolonged LOS (8.0%), 514 had 90-day postdischarge deaths without readmission (1.3 %), and 7701 had one or more 90-day readmissions (19.5%); 10,924 patients (27.7%) had one or more of these OAs. Twenty-six hospitals were two SDs better than predicted and 34 hospitals were two SDs poorer than predicted. When evaluated by deciles of risk-adjusted OAs, the top performing decile of hospitals had rates of 14.3% and the poorest performing decile had OA rates of 41.0%. CONCLUSIONS: The differences in risk-adjusted comparative outcomes between top- and suboptimal-performing hospitals in lung resections define the potential opportunities for care improvement. Identification of risk factors associated with OAs and causes for readmissions provides direction for specific areas of care redesign for improvement.


Subject(s)
Aftercare , Medicare , Aged , Humans , Length of Stay , Lung , Patient Discharge , Patient Readmission , Risk Adjustment , United States
2.
Neurosurgery ; 85(1): E109-E115, 2019 07 01.
Article in English | MEDLINE | ID: mdl-30137526

ABSTRACT

BACKGROUND: Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs). OBJECTIVE: To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care. METHODS: The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr. Predictive logistic models were designed for inpatient mortality, inpatient prolonged length of stay, 90-d postdischarge deaths without readmission, and 90-d readmissions after exclusions. The total observed patients with one or more AOs were then compared to predicted AO values, and z-scores were computed for each hospital that met minimum volume requirements. Risk-adjusted AO rates allowed stratification of eligible hospitals into deciles of performance. RESULTS: The hospital evaluation was performed for 223 facilities with 7624 patients that met criteria. A total of 849 patients (11.1%) died inclusive of 90 d postdischarge; 635 (8.3%) were 3σ length-of-stay outliers; and 1928 patients (25.3%) with one or more 90-d readmissions; 2716 patients experienced one or more AOs (35.6%). Six hospitals were 2 z-scores better than average, and 8 were 2 z-scores poorer. The median risk-adjusted AO rate was 18% for the first decile and 53.4% for the 10th decile. CONCLUSION: There was a 35% difference between best and suboptimal performing hospitals for this operation. Hospitals must know their risk-adjusted AO rates and benchmark their results to inform processes of care redesign.


Subject(s)
Benchmarking , Craniotomy/adverse effects , Postoperative Complications , Aged , Elective Surgical Procedures/adverse effects , Female , Humans , Inpatients , Length of Stay/statistics & numerical data , Logistic Models , Male , Middle Aged , Patient Readmission/statistics & numerical data , Postoperative Complications/epidemiology , Postoperative Complications/etiology , United States
3.
Medicine (Baltimore) ; 97(37): e12269, 2018 Sep.
Article in English | MEDLINE | ID: mdl-30212962

ABSTRACT

It is important that actual outcomes of care and not surrogate markers, such as process measures, be used to evaluate the quality of inpatient care. Because of the heterogenous composition of patients, risk-adjustment is essential for the objective evaluation of outcomes following inpatient care. Comparative evaluation of risk-adjusted outcomes can be used to identify suboptimal performance and can provide direction for care improvement initiatives.We studied the risk-adjusted outcomes of 6 medical conditions during the inpatient and 90-day post-discharge period to identify the opportunities for care improvement. The Medicare Limited Dataset for 2012 to 2014 was used to identify acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia (PNEU), cerebrovascular accidents (CVA), and gastrointestinal hemorrhage (GIH). Stepwise logistic predictive models were developed for the adverse outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths, and 90-day readmissions after unrelated events were excluded. Observed and predicted AOs were determined for each hospital with ≥75 cases for each of the 6 medical conditions. Z-scores and risk-adjusted AO rates for each hospital permitted comparative analysis of outcomes after adjusting for covariance among the medical conditions.There were a total of 1,811,749 patients from 973 acute care hospitals with the 6 medical conditions. A total of 41% of all patients had ≥1 AO events. One or more readmissions were identified in 29.8% of patients. A total of 64 hospitals (6.4%) were 2 standard deviations better than the mean for risk-adjusted outcomes, and 72 (7.4%) were 2 standard deviations poorer. The best performing decile of hospitals had mean AO rates of 35.1% (odds ratio = 0.766; 95% confidence interval (CI) CI: 0.762-0.771) and the poorest performing decile a mean AO rate of 48.5% (odds ratio = 1.357; 95% CI: 1.346-1.369). Volume of qualifying cases ranged from 670 to 9314; no association was identified for increased volume of patients (P < .40).Risk-adjusted AO rates demonstrated nearly a 14% opportunity for care improvement between top and suboptimal performing hospitals. Hospitals must be able to benchmark objective measurement of outcomes to inform quality initiatives.


Subject(s)
Hospitalization/statistics & numerical data , Inpatients/statistics & numerical data , Medicare/statistics & numerical data , Outcome Assessment, Health Care/statistics & numerical data , Aged , Benchmarking , Hospital Mortality , Humans , Length of Stay , Patient Readmission , Quality Indicators, Health Care , Quality of Health Care/statistics & numerical data , Risk Adjustment , United States
4.
Surgery ; 164(4): 831-838, 2018 10.
Article in English | MEDLINE | ID: mdl-29941284

ABSTRACT

BACKGROUND: Risk-adjusted outcomes of elective major vascular surgery that is inclusive of inpatient and 90-day post-discharge adverse outcomes together have not been well studied. METHODS: We studied 2012-2014 Medicare inpatients who received open aortic procedures, open peripheral vascular procedures, endovascular aortic procedures, and percutaneous angioplasty procedures of the lower extremity for risk-adjusted adverse outcomes of inpatient deaths, 3-sigma prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day post-discharge associated readmissions after excluding unrelated events. Observed and predicted total adverse outcomes for hospitals meeting minimum risk-volume criteria were assessed and hospital-specific z-scores and risk-adjusted adverse outcomes were calculated to compare performance. RESULTS: The total adverse-outcome rate was 27.8% for open aortic procedures, 31.5% for open peripheral vascular procedures, 19.6% for endovascular aortic procedures, and 36.4% for percutaneous angioplasty procedures. The difference in risk-adjusted adverse-outcome rates between the best- and the poorest-performing deciles were 32.2% for open aortic procedures, 29.5% for open peripheral vascular procedures, 21.5% for endovascular aortic procedures, and 37.1% for percutaneous angioplasty procedures. The 90-day post-discharge deaths and readmissions were the major driver of overall adverse-outcome rates. CONCLUSION: The variability in risk-adjusted outcomes among best- and poorest-performing hospitals is over 20% in all major vascular procedures and indicates that a large opportunity exists for improvement in results.


Subject(s)
Elective Surgical Procedures/adverse effects , Elective Surgical Procedures/statistics & numerical data , Vascular Diseases/surgery , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/statistics & numerical data , Comorbidity , Elective Surgical Procedures/mortality , Humans , Medicare/statistics & numerical data , Risk Adjustment/statistics & numerical data , Risk Factors , Treatment Outcome , United States/epidemiology , Vascular Diseases/epidemiology , Vascular Surgical Procedures/mortality
5.
Am Surg ; 84(1): 12-19, 2018 Jan 01.
Article in English | MEDLINE | ID: mdl-29428014

ABSTRACT

More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.6 per cent in OC versus 20.9 per cent in laparoscopic cholecystectomy. Conversion of laparoscopic to open procedures was not associated with increased adverse outcomes. Laparoscopic cholecystectomy provides patients with many advantages, but when clinical circumstances are necessary, OC continues to be performed with the same overall adverse outcome rates, and the conversion process is not associated with poorer results in this high-risk population of patients.


Subject(s)
Cholecystectomy , Hospital Mortality , Length of Stay , Medicaid , Medicare , Patient Discharge , Patient Readmission , Aged , Aged, 80 and over , Cholecystectomy/adverse effects , Cholecystectomy, Laparoscopic/adverse effects , Conversion to Open Surgery , Humans , Retrospective Studies , Risk Assessment , Risk Factors , Treatment Outcome , United States
6.
Am J Surg ; 215(3): 430-433, 2018 Mar.
Article in English | MEDLINE | ID: mdl-28954711

ABSTRACT

BACKGROUND: Regional differences in utilization of services in healthcare are commonly understood, but risk-adjusted evaluation of outcomes has not been done. METHODS: Risk-adjusted adverse outcomes (AOs) for elective Medicare colorectal resections were studied for 2012-2014. Risk-adjusted metrics were inpatient deaths, prolonged postoperative length-of-stay, 90-day post-discharge deaths, and 90-day relevant post-discharge readmissions. The nine Census Bureau regions of the U.S. were evaluated by using standard deviations of predicted adverse outcomes to evaluate observed versus expected events. RESULTS: Overall AO rate was 24.3% from 86,624 patients in 1497 hospitals. Region 9 (Pacific) had the best outcomes (z-score = -3.06; risk-adjusted AO rate = 22.9%) and Region 1 (New England) the poorest (z-score = +1.86; risk-adjusted AO rate = 25.4%). CONCLUSIONS: A 4.9 SD difference exists among the best and poorest performing regions in risk-adjusted colorectal surgery outcomes. Alternative Payment Models should consider regional benchmarks as a variable for the evaluation of quality and pricing of episodes of care.


Subject(s)
Colectomy , Elective Surgical Procedures , Healthcare Disparities/statistics & numerical data , Medicare , Outcome Assessment, Health Care , Proctectomy , Risk Adjustment , Aged , Aged, 80 and over , Colectomy/standards , Female , Humans , Logistic Models , Male , Proctectomy/standards , United States
7.
Surgery ; 163(3): 606-611, 2018 03.
Article in English | MEDLINE | ID: mdl-29229316

ABSTRACT

BACKGROUND: The risk-adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90-day postdischarge adverse outcomes have not been studied. METHODS: We studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012-2014. Risk-adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3-sigma prolonged duration-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day postdischarge associated readmissions. Standard deviations of predicted overall adverse outcomes were computed for each hospital. Hospital-specific z scores and risk-adjusted adverse outcomes were calculated. RESULTS: There were 77,086 carotid endarterectomy patients from 960 hospitals complicated by 191 inpatient deaths (0.25%), 4,436 prolonged duration of stay (5.8%), 457 90-day postdischarge deaths (0.6%), and 7,956 90-day postdischarge associated readmissions (10.3%). In the 90-day postdischarge associated readmission patients, an additional 561 patients died after readmission, for total deaths of 1,209 (1.6%) for the study period, and 11,928 (15.5%) patients had one or more adverse outcomes. There were 29 best-performing hospitals (3.0%) with z scores of -2.0 or less (P < .05) with a median rate of risk-adjusted adverse outcomes of 7.1%. A total of 61 suboptimal performers (6.3%) had z scores of +2.0 or greater (P < .05) with a median rate of risk-adjusted adverse outcome rate of 26.4%. CONCLUSION: Hospital risk-adjusted adverse outcome rates for carotid endarterectomy are highly variable. Comparisons of hospital performance define the opportunity for improvement.


Subject(s)
Carotid Artery Diseases/surgery , Elective Surgical Procedures/adverse effects , Endarterectomy, Carotid/adverse effects , Hospitalization , Medicare , Postoperative Complications/epidemiology , Aged , Carotid Artery Diseases/complications , Carotid Artery Diseases/mortality , Female , Hospital Mortality , Humans , Logistic Models , Male , Outcome Assessment, Health Care , Retrospective Studies , Risk Adjustment , United States
8.
Am J Surg ; 215(3): 367-370, 2018 Mar.
Article in English | MEDLINE | ID: mdl-29100592

ABSTRACT

BACKGROUND: Preoperative emergency department (ED) visits may reflect the patient's biliary disease, or may signal unstable comorbid conditions that have relevance following inpatient laparoscopic cholecystectomy (ILC) and outpatient laparoscopic cholecystectomy (OLC) in Medicare patients. METHODS: We used the Medicare inpatient and outpatient Limited Datasets to identify elective laparoscopic cholecystectomy patients from 2011 to 2014. ED visits for 30-days before the surgical event were identified and correlated with the probability of patients returning to the ED in the 30-days following the procedure. RESULTS: A total of 129,377 inpatient and 235,339 outpatient LCs were identified. A total of 20,021 (15.5%) of ILCs and 52,025 (22.1%) of OLCs had 30-day preoperative ED visits. ILCs with any 30-day ED visit preoperatively had an Odds Ratio (OR) that predicted a post-discharge ED visit of 1.85 (95% CI = 1.78-1.92; P < 0.0001). OLCs with any 30-day ED visit preoperatively had an OR for post-discharge ED visit of 1.50 (95% CI = 1.46-1.54; P < 0.0001). CONCLUSION: Preoperative ED visits predict postdischarge ED visits for laparoscopic cholecystectomy in Medicare patients.


Subject(s)
Ambulatory Surgical Procedures , Cholecystectomy, Laparoscopic , Emergency Service, Hospital/statistics & numerical data , Facilities and Services Utilization/statistics & numerical data , Hospitalization , Medicare , Aged , Aged, 80 and over , Elective Surgical Procedures , Female , Humans , Male , Postoperative Period , Preoperative Period , United States
9.
Spine J ; 17(11): 1641-1649, 2017 11.
Article in English | MEDLINE | ID: mdl-28662991

ABSTRACT

BACKGROUND CONTEXT: Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs. PURPOSE: To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery. STUDY DESIGN/SETTING: To identify the significant risk factors associated with AOs and to develop risk models that measure performance. PATIENT SAMPLE: Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset. OUTCOME MEASURES: The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models. METHODS: Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals. RESULTS: There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%. CONCLUSIONS: Differences among hospitals defines opportunities for care improvement.


Subject(s)
Elective Surgical Procedures/adverse effects , Medicare/statistics & numerical data , Patient Discharge/statistics & numerical data , Postoperative Complications/epidemiology , Spinal Fusion/adverse effects , Aged , Elective Surgical Procedures/economics , Female , Humans , Inpatients/statistics & numerical data , Male , Middle Aged , Patient Readmission/statistics & numerical data , Spinal Fusion/economics , United States
10.
J Bone Joint Surg Am ; 99(1): 10-18, 2017 Jan 04.
Article in English | MEDLINE | ID: mdl-28060228

ABSTRACT

BACKGROUND: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison. METHODS: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied. Logistic risk models were designed for adverse outcomes of inpatient mortality, prolonged length-of-stay outliers in the index hospitalization, 90-day post-discharge deaths without readmission, and 90-day readmissions after excluding non-related readmissions. For each hospital, models were used to predict total adverse outcomes, the number of standard deviations from the mean (z-scores) for hospital performance, and risk-adjusted adverse outcomes for each hospital. RESULTS: A total of 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement were studied. The observed overall adverse outcome rates were 12.0% for total hip replacement and 11.6% for total knee replacement. The z-scores for 1,483 hospitals performing total hip replacements varied from -5.09 better than predicted to +5.62 poorer than predicted; 98 hospitals were ≥2 standard deviations better than predicted and 142 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.6% for the best-decile hospitals and 19.8% for the poorest-decile hospitals. The z-scores for the 2,349 hospitals performing total knee replacements varied from -5.85 better than predicted to +11.75 poorer than predicted; 223 hospitals were ≥2 standard deviations better than predicted and 319 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.4% for the best-decile hospitals and 19.3% for the poorest-decile hospitals. CONCLUSIONS: Risk-adjusted outcomes demonstrate wide variability and illustrate the need for improvement among poorer-performing hospitals for bundled payments of joint replacement surgical procedures. CLINICAL RELEVANCE: Adverse outcomes are known to occur in the experience of all clinicians and hospitals. The risk-adjusted benchmarking of hospital performance permits the identification of adverse events that are potentially preventable.


Subject(s)
Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Knee/adverse effects , Arthroplasty, Replacement, Hip/mortality , Arthroplasty, Replacement, Hip/statistics & numerical data , Arthroplasty, Replacement, Knee/mortality , Arthroplasty, Replacement, Knee/statistics & numerical data , Female , Hospitals/standards , Hospitals/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Male , Medicare/statistics & numerical data , Patient Discharge/statistics & numerical data , Patient Outcome Assessment , Quality Improvement , Reimbursement, Incentive , Risk Adjustment , United States/epidemiology
11.
Ann Surg ; 265(1): 178-184, 2017 01.
Article in English | MEDLINE | ID: mdl-28009744

ABSTRACT

OBJECTIVE: To compare the risk-adjusted outcomes of hospitals in inpatient Medicare laparoscopic cholecystectomy. BACKGROUND: Reduced length-of-stay for inpatient surgical care requires the inclusion of objective postdischarge outcomes to provide a comprehensive assessment of hospital and surgeon performance for quality improvement. METHODS: The 2010 to 2012 Medicare Limited Data Set was used to develop risk-adjusted prediction models of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths, and 90-day readmissions for inpatient laparoscopic cholecystectomy. To define the opportunity for improved performance, prediction models were used to compute z scores and risk-adjusted adverse outcome rates for all hospitals in the database that had 20 or more evaluable cases for the study period. RESULTS: A total of 83,274 patients from 1570 hospitals had an overall adverse outcome rate of 20.7%; 48 hospitals had outcomes that were 2 z scores better than predicted and 76 had 2 z scores poorer than predicted. Risk-adjusted adverse outcomes were 10.0 % in the best performing decile of hospitals and were 32.1% in the poorest performing decile. Gastrointestinal, infectious, and cardiopulmonary complications of care were the most common causes of readmissions with 46.3% occurring between days 30 and 90 after discharge. CONCLUSIONS: Comparative analysis of overall risk-adjusted inpatient and 90-day postdischarge adverse outcomes identifies considerable opportunity for improved care in this high-risk population of patients.


Subject(s)
Benchmarking , Cholecystectomy, Laparoscopic , Hospital Mortality , Length of Stay/statistics & numerical data , Medicare , Patient Readmission/statistics & numerical data , Risk Adjustment , Aged , Aged, 80 and over , Cholecystectomy, Laparoscopic/mortality , Female , Humans , Logistic Models , Male , Outcome Assessment, Health Care , Quality Improvement , Quality Indicators, Health Care/statistics & numerical data , United States
12.
Medicine (Baltimore) ; 95(36): e4784, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27603382

ABSTRACT

Without risk-adjusted outcomes of surgical care across both the inpatient and postacute period of time, hospitals and surgeons cannot evaluate the effectiveness of current performance in nephrectomy and other operations, and will not have objective metrics to gauge improvements from care redesign efforts.We compared risk-adjusted hospital outcomes following elective total and partial nephrectomy to demonstrate differences that can be used to improve care. We used the Medicare Limited Dataset for 2010 to 2012 for total and partial nephrectomy for benign and malignant neoplasms to create prediction models for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day relevant readmissions. From the 4 prediction models, total predicted adverse outcomes were determined for each hospital in the dataset that met a minimum of 25 evaluable cases for the study period. Standard deviations (SDs) for each hospital were used to identify specific z-scores. Risk-adjusted adverse outcomes rates were computed to permit benchmarking each hospital's performance against the national standard. Differences between best and suboptimal performing hospitals defined the potential margin of preventable adverse outcomes for this operation.A total of 449 hospitals with 23,477 patients were evaluated. Overall AO rate was 20.8%; 17 hospitals had risk-adjusted AO rates that were 2 SDs poorer than predicted and 8 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 10.2% while the lowest performing decile had 32.1%. With a minimum of 25 cases for each study hospital, no statistically valid improvement in outcomes was seen with increased case volume.Inpatient and 90-day postdischarge risk-adjusted adverse outcomes demonstrated marked variability among study hospitals and illustrate the opportunities for care improvement. This analytic design is applicable for comparing provider performance across a wide array of different inpatient episodes.


Subject(s)
Hospitalization/statistics & numerical data , Hospitals/standards , Kidney Neoplasms/surgery , Nephrectomy/adverse effects , Nephrectomy/statistics & numerical data , Aged , Aged, 80 and over , Benchmarking , Female , Hospital Mortality , Hospitals/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Logistic Models , Male , Medicare , Nephrectomy/mortality , Patient Readmission/statistics & numerical data , Risk Adjustment , Treatment Outcome , United States
13.
Am J Surg ; 212(1): 10-5, 2016 Jul.
Article in English | MEDLINE | ID: mdl-27242219

ABSTRACT

BACKGROUND: Risk-adjusted outcomes are essential for hospitals to benchmark care improvement. METHODS: We used the Medicare Limited Data Set for 2010 to 2012 to create risk models in elective colon surgery for the adverse outcomes (AOs) of inpatient deaths, prolonged length-of-stay outliers, 90-day post-discharge deaths without readmission, and 90-day relevant readmissions. Risk models permitted the prediction of AOs for each hospital and the design of hospital-specific standard deviations (SDs) to define performance from observed values. Risk-adjusted AO rates were computed for hospital comparisons. RESULTS: In all, 1,903 hospitals with 129,861 patients were studied. Overall AO rate was 27.8%; 84 hospitals had AO performance that was 2 SDs poorer than average and 66 were 2 SDs better. The top performing decile of hospitals had a risk-adjusted AO rate of 15.8%, whereas the lowest performing hospital's rate was 39.4%. CONCLUSIONS: Benchmarking risk-adjusted AOs identifies the opportunity for care improvement in elective colon surgery in Medicare patients.


Subject(s)
Benchmarking , Colorectal Surgery/statistics & numerical data , Elective Surgical Procedures/statistics & numerical data , Medicare/statistics & numerical data , Outcome Assessment, Health Care , Patient Readmission/statistics & numerical data , Aged , Aged, 80 and over , Colorectal Surgery/methods , Databases, Factual , Elective Surgical Procedures/methods , Female , Hospital Mortality , Humans , Length of Stay , Logistic Models , Male , Patient Discharge/statistics & numerical data , Retrospective Studies , United States
14.
Am J Surg ; 211(3): 577-82, 2016 Mar.
Article in English | MEDLINE | ID: mdl-26762831

ABSTRACT

BACKGROUND: Readmissions after inpatient care are being used as a metric for clinical outcomes for surgeons and hospitals, but without standardization of the appropriate postdischarge period. METHODS: Elective colon surgery (ECS) for Medicare patients was reviewed to define the frequency and causes of readmission at 30, 60, and 90 days after discharge. Elective, trauma, and cancer readmissions were excluded. A prediction model at 90 days after discharge was designed to identify risk factors that were associated with readmissions. RESULTS: A total of 107,459 live discharges after ECS had 12,746 readmissions at 30 days, 4,601 1st-time readmissions at 31 to 60 days, and another 4,042 1st-time readmissions from days 61 to 90; 40% of initial and nearly 50% of all readmissions occurred from days 31 to 90. Primary causes for readmission were gastrointestinal, infectious, and cardiopulmonary events. CONCLUSIONS: The 90-day postdischarge time period provides the most accurate measurement interval for relevant readmissions after ECS.


Subject(s)
Colonic Diseases/surgery , Elective Surgical Procedures , Medicare , Patient Readmission/statistics & numerical data , Aged , Aged, 80 and over , Diagnosis-Related Groups , Female , Humans , Length of Stay/statistics & numerical data , Male , Postoperative Complications/epidemiology , Risk Factors , United States/epidemiology
15.
Surgery ; 158(4): 1056-62; discussion 1062-4, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26162940

ABSTRACT

BACKGROUND: Longitudinal, risk-adjusted measurement of outcomes of carotid artery (CA) surgery is necessary for the evaluation of quality performance and for the assessment of strategies of quality improvement. METHODS: Patients from quality coding hospitals who underwent CA surgery and met procedural and diagnostic coding requirements in the Medicare Inpatient Limited Data Set from 2009 to 2011 were used to design logistic prediction models for the Adverse Outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers (prLOS) among live discharges, 90-day post-discharge deaths without readmission (PD-90), and 90-day post-discharge readmissions (ReAdm-90). RESULTS: A total of 653 quality coding hospitals had 54,183 CA surgery cases. There were 122 inpatient deaths (0.23%) and 3,337 (6.2%) prLOS. After discharge, there were 258 patients that were PD-90 and 9,804 patients (18.1 % of live discharges) were readmitted. Among all readmissions, 1,592 (13.3%) were judged to be totally unrelated to the index operation. A total of 495 patients died during readmission to the hospital. The rate of total adverse outcome was 22.6% with all ReAdm-90 cases counted. CONCLUSION: In CA surgery, more AOs occur in the 90 days after discharge than during the inpatient period of care. ReAdm-90 remains the major cause for AOs and represents the greatest opportunity for improvement in the care of CA surgery patients.


Subject(s)
Carotid Artery Diseases/surgery , Endarterectomy, Carotid , Hospital Mortality , Length of Stay/statistics & numerical data , Medicare , Patient Readmission/statistics & numerical data , Postoperative Complications/epidemiology , Aged , Aged, 80 and over , Carotid Artery Diseases/mortality , Endarterectomy, Carotid/mortality , Female , Humans , Logistic Models , Male , Patient Discharge , Postoperative Complications/etiology , Quality Improvement , Quality Indicators, Health Care/statistics & numerical data , Risk Adjustment , United States
16.
J Am Coll Surg ; 221(1): 102-9, 2015 Jul.
Article in English | MEDLINE | ID: mdl-26027503

ABSTRACT

BACKGROUND: Objective measurement of outcomes in surgical care lack standard definitions, effective and consistent surveillance, and identification of significant postdischarge events. STUDY DESIGN: Using the Medicare Inpatient file (2009 to 2011), we designed logistic prediction models for inpatient mortality, prolonged length of stay (prLOS) as a measure of serious inpatient complications, and all-cause 90-day postdischarge (90-DPd) deaths and hospital readmissions for elective and nonelective laparoscopic cholecystectomy (LC). Qualifying hospitals had more than 20 cases for the study period and met rigorous present-on-admission coding standards. RESULTS: A total of 902 hospitals had 64,021 LCs. There were 509 inpatient deaths (0.8%) and 4,624 (7.2%) were prLOS. At 90-DPd, 729 patients died without readmission with a prediction model of 15 variables (C-statistic = 0.848), and 11,052 patients (17.4% of live discharges) were readmitted (1,165 died) with a prediction model of 36 variables (C-statistic = 0.674). Among significant (p < 0.0001) odds ratios (ORs), 90-DPd deaths were associated with age greater than 84 years (OR 3.7), prLOS (OR 7.8), operations performed on day 3 or thereafter in the index hospitalization (OR 1.6), and other chronic disease variables. Similar variables were associated with 90-DPd readmissions. A composite measure of all inpatient and 90-DPd deaths, prLOS for the index hospitalization, and 90-DPd readmissions resulted in an overall adverse outcome rate of 23.7% (15,195 of 64,021). CONCLUSIONS: Adverse outcomes of inpatient deaths, prLOS, and 90-DPd readmissions and deaths provide an objective target for care redesign and improvement. The postdischarge period is the greatest source of adverse outcomes in LC. Composite measurement of adverse outcomes becomes a meaningful tool for the design of surgical warranties for episode-based payment initiatives.


Subject(s)
Cholecystectomy, Laparoscopic , Decision Support Techniques , Outcome Assessment, Health Care/methods , Adult , Aged , Aged, 80 and over , Cholecystectomy, Laparoscopic/mortality , Female , Hospital Mortality , Humans , Length of Stay/statistics & numerical data , Logistic Models , Male , Medicare , Middle Aged , Odds Ratio , Patient Readmission/statistics & numerical data , Postoperative Complications , Risk Adjustment , Risk Assessment , United States
17.
Am J Surg ; 209(3): 509-14, 2015 Mar.
Article in English | MEDLINE | ID: mdl-25586598

ABSTRACT

BACKGROUND: The 90-day postdischarge morbidity and mortality rates following elective and emergent bowel surgery remain poorly defined. METHODS: The 2009 to 2011 Medicare inpatient files for patients undergoing elective and emergent small and large bowel operations in 1,024 hospitals that passed present-on-admission coding accuracy standards had prediction models designed for inpatient mortality, prolonged postoperative length of hospital stay (prLOS), 90-day postdischarge mortality and readmissions, and total hospital costs. RESULTS: Of 118,758 patients studied, there was a 4.7% inpatient mortality rate and 7.3% prLOS among live discharges. An additional 7,586 deaths and 26,969 readmissions occurred within 90 days of discharge. Prolonged preoperative and prolonged postoperative hospitalizations were significant (P < .0001) variables in predicting postdischarge deaths and readmissions. Total hospital costs were increased by over $18,000 per adverse outcome. CONCLUSION: Postdischarge deaths and readmissions are more common than inpatient adverse events of death and prLOS in elective and emergent Medicare large and small bowel operations.


Subject(s)
Digestive System Surgical Procedures/economics , Elective Surgical Procedures/economics , Hospital Costs/trends , Intestinal Diseases/surgery , Medicare/statistics & numerical data , Patient Discharge/trends , Patient Readmission/trends , Aged , Aged, 80 and over , Costs and Cost Analysis , Female , Follow-Up Studies , Humans , Intestinal Diseases/economics , Intestine, Small/surgery , Length of Stay/trends , Male , Morbidity , Postoperative Complications/economics , Postoperative Complications/epidemiology , Retrospective Studies , Risk Factors , Survival Rate/trends , United States/epidemiology
18.
Surgery ; 156(4): 931-6, 2014 Oct.
Article in English | MEDLINE | ID: mdl-25239349

ABSTRACT

BACKGROUND: Little information is available about postdischarge adverse events after laparoscopic cholecystectomy. METHODS: Inpatient and 90-day postdischarge adverse events were identified for Medicare patients discharged in 2009-2010 after undergoing elective laparoscopic cholecystectomy on day 0, 1, or 2 of hospitalization at facilities that performed 20 or more laparoscopic cholecystectomies during the study period. A predictive length of stay (LOS) linear regression model was derived and used to identify patients with prolonged LOS (prLOS) whose risk-adjusted LOS exceeded a 3σ upper limit on a moving average control chart. Rates of inpatient and 90-day fatal and nonfatal adverse events and interrelationships among different outcomes and alternative outcome measures were explored. RESULTS: Of 89,639 study cases, 0.7% died during their index hospitalization, and 1.3% died within 90 days of discharge. Of live discharges, 8.0% had prLOS, and 42.1% had coded complication. In the 90 days after discharge, 9,416 (10.6%) were readmitted. Patients who were prLOS outliers were more likely to die or be readmitted than nonoutliers (P < .0001; χ(2)). CONCLUSION: More than 18% of Medicare patients undergoing presumably low-risk elective inpatient laparoscopic cholecystectomy died, had a severe inpatient complication, or were readmitted within 90 days of discharge.


Subject(s)
Cholecystectomy, Laparoscopic/mortality , Elective Surgical Procedures/mortality , Patient Readmission/statistics & numerical data , Postoperative Complications , Aged , Aged, 80 and over , Follow-Up Studies , Humans , Length of Stay/statistics & numerical data , Linear Models , Medicare , Outcome Assessment, Health Care , Patient Discharge , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Risk Factors , United States
19.
Am J Surg ; 207(3): 326-30; discussion 330, 2014 Mar.
Article in English | MEDLINE | ID: mdl-24418180

ABSTRACT

BACKGROUND: The frequency of 90-day, postdischarge deaths and readmissions in Medicare patients undergoing elective surgical procedures has not been well studied. METHODS: The Medicare MedPar database for 2009 to 2010 was used to develop inpatient risk-adjusted, postoperative length-of-stay (RApoLOS) prediction models for live discharges in 21 categories of elective operations. Moving average control charts were used in each category to define RApoLOS outliers (>3σ). The relationships between RApoLOS outliers and all postdischarge deaths and readmissions within 90 days of discharge were assessed. RESULTS: The inpatient mortality rate was .5%. Of 2,054,189 live discharges, 147,292 (7%) were RApoLOS outliers. There were 14,657 postdischarge deaths (.7%) and 187,566 readmissions (9%). RApoLOS outliers had a 3.5% death rate and a 17% rate of readmission, while those found not to be RApoLOS outliers had a .5% death rate and a 9% readmission rate (P < .0001). CONCLUSIONS: RApoLOS outliers have increased rates of postdischarge deaths and readmissions.


Subject(s)
Elective Surgical Procedures/statistics & numerical data , Medicare/statistics & numerical data , Patient Discharge/statistics & numerical data , Patient Readmission/statistics & numerical data , Elective Surgical Procedures/mortality , Humans , Length of Stay/statistics & numerical data , Risk Adjustment , Risk Factors , United States/epidemiology
20.
Med Care ; 48(10): 862-8, 2010 Oct.
Article in English | MEDLINE | ID: mdl-20808259

ABSTRACT

BACKGROUND: Unit costs of health services are substantially higher in the United States than in any other developed country in the world, without a correspondingly healthier population. An alternative payment structure, especially for high volume, high cost episodes of care (eg, total knee replacement), is needed to reward high quality care and reduce costs. METHODS: The National Inpatient Sample of administrative claims data was used to measure risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. Empirically identified inefficient and ineffective hospitals were then removed to create a reference group of high-performance hospitals. Predictive models for outcomes and costs were recalibrated to the reference hospitals and used to compute risk-adjusted outcomes and costs for all hospitals. Per case predicted costs were computed and compared with observed costs. RESULTS: Of the 688 hospitals with acceptable data, 62 failed to meet effectiveness criteria and 210 were identified as inefficient. The remaining 416 high-performance hospitals had 13.4% fewer risk-adjusted adverse outcomes (4.56%-3.95%; P < 0.001; χ) and 9.9% lower risk-adjusted total costs ($12,773-$11,512; P < 0.001; t test) than all study hospitals. Inefficiency accounted for 96% of excess costs. CONCLUSIONS: A payment system based on the demonstrated performance of effective, efficient hospitals can produce sizable cost savings without jeopardizing quality. In this study, 96% of total excess hospital costs resulted from higher routine costs at inefficient hospitals, whereas only 4% was associated with ineffective care.


Subject(s)
Arthroplasty, Replacement, Knee/economics , Hospital Charges/statistics & numerical data , Hospital Costs/statistics & numerical data , Reimbursement Mechanisms/economics , Adult , Aged , Aged, 80 and over , Arthroplasty, Replacement, Knee/statistics & numerical data , Cost Control/statistics & numerical data , Cost-Benefit Analysis , Efficiency, Organizational , Fee-for-Service Plans/economics , Female , Humans , Length of Stay/economics , Male , Middle Aged , Osteoarthritis, Knee/economics , United States , Young Adult
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