Impact of race on the outcome of carotid endarterectomy: a population-based analysis of 9,842 recent elective procedures.

OBJECTIVE: To examine the influence of race and other potentially confounding variables on the outcome of carotid endarterectomy (CEA). SUMMARY: Previous studies have demonstrated that CEA is performed less frequently in black patients, although little attention has been focused on the influence of race on the outcome of surgery. METHODS: The Maryland Health Services Cost Review Commission database was reviewed to identify all elective CEA procedures performed in all nonfederal acute care hospitals in the state from 1990 through 1995 to examine the influence of race and other factors on the rates of in-hospital complications, in-hospital stroke, length of stay, and total hospital charges. RESULTS: Carotid endarterectomy was performed in 9,219 (94%) white and 623 (6%) black patients during this period. The in-hospital stroke rate was 1.7%-3. 1% among black patients and 1.6% among white patients. Black patients had a longer length of stay and higher mean hospital charges than white patients. Multivariate logistic regression analysis identified black race as an independent risk factor for in-hospital stroke. Performance of CEA by a high-volume surgeon was protective for the combined occurrence of in-hospital stroke or death, and whites were more than twice as likely to undergo surgery performed by high-volume surgeons. Conversely, undergoing surgery in a low-volume hospital was associated with in-hospital stroke, and blacks were four times as likely to use low-volume hospitals. CONCLUSIONS: Black patients who underwent elective CEA in Maryland from 1990 to 1995 had an increased incidence of in-hospital stroke, a longer hospital stay, and higher hospital charges than whites. Black race was identified as an independent risk factor for in-hospital stroke, although the reasons for this influence of race on outcome are undefined. The authors' observations also suggest the possibility of limited access to optimal surgical care among blacks, and this issue warrants further study.

Clinical pathway implementation improves outcomes for complex biliary surgery.

BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection.

OBJECTIVE: To examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. METHODS: The study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume--low (< or =5), medium (5 to 10), and high (>10)--and hospital volume--low (<40), medium (40 to 70), and high (> or =70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. RESULTS: During the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The low-volume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high- or medium-volume hospitals. CONCLUSIONS: A skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed >10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in low-volume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.

Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes.

BACKGROUND: Commonly performed elective gastrointestinal surgical procedures are carried out with low morbidity and mortality in hospitals throughout the United States. Complex operative procedures on the alimentary tract are performed with a relatively low frequency and are associated with higher mortality. Volume and experience of the surgical provider team have been correlated with better clinical and economic outcomes for one complex gastrointestinal surgical procedure, pancreaticoduodenectomy. This study evaluated whether provider volume and experience were important factors influencing clinical and economic outcomes for a variety of complex gastrointestinal surgical procedures in one state. STUDY DESIGN: Complex high-risk gastrointestinal surgical procedures were defined as those with statewide in-hospital mortality of > or = 5%, frequency of greater than 200 per year in the state, and requiring special surgical skill and expertise. Six procedures met these criteria. Using publicly available discharge data, all patients discharged from Maryland hospitals from July 1989 to June 1997 with a primary procedure code for one of the six study procedures were selected. Hospitals were classified into one of six groups based on the average number of study procedures per year: 10 or less; 11 to 20; 21 to 50; 51 to 100; 101 to 200; and 201 or more procedures per year. A hospital was included if at least one procedure was performed there during the study period. No providers fell within the 51 to 100, and 101 to 200 groups, so all analyses were performed for the remaining four volume groups that were classified, respectively, as minimal (10 or fewer procedures), low (11 to 20 procedures), medium (21 to 50 procedures), and high-volume groups (201 or more procedures). Poisson regression was used to assess the relationship between in-hospital mortality and hospital volume after case-mix adjustment. Multiple linear regression models were used to assess differences in average length-of-stay and average total hospital charges among hospital volume groups. We further analyzed mortality, length-of-stay, and charges at the procedural level to understand these subgroups of complex gastrointestinal patients. We also examined the relationship between provider volume and outcomes for malignant versus benign diagnosis groups. RESULTS: Complex gastrointestinal surgical procedures were performed on 4,561 patients in Maryland from July 1989 through June 1997. The study population averaged 61.6 years of age, was 55% male, 71% Caucasian, and had predominantly Medicare as a payment source. After case-mix adjustment, patients who underwent complex gastrointestinal surgical procedures at the medium-, low-, and minimal-volume provider groups had a 2.1, 3.3, and 3.2 times greater risk of in-hospital death, respectively, than patients at the high-volume provider (p < 0.001 for all comparisons); longer lengths-of-stay, 16.1, 15.7, and 15.5 days at the low-, medium-, and minimal-volume groups, respectively, versus 14.0 days for the high-volume provider (p < 0.001 for all comparisons). Similarly, adjusted charges at the high-volume provider were, on average, 14% less than those of the low-volume group, which had the next lowest charges. Although mortality rates differed by procedure type, for each procedure, mortality increased as provider volume decreased, following the pattern found in the aggregate analysis. After case-mix adjustment, the risk of in-hospital death for patients with malignant diagnoses was significantly higher for the medium-, low-, and minimal-volume groups compared with patients at the high-volume provider, relative risk of 3.1, 4.0, and 4.2, respectively, (p < 0.001 for all comparisons). CONCLUSIONS: This study demonstrates that increased hospital experience is associated with a marked decrease in hospital mortality. The decreased mortality at the high-volume provider was also associated with shorter lengths-of-stay and lower hospital char

Cost implications of different surgical management strategies for primary hyperparathyroidism.

BACKGROUND: Controversy exists about optimal management of patients with primary hyperparathyroidism. To date, no studies have explored the cost implications of variation in practice. METHODS: Results from a national survey of endocrine surgeons were combined with results from a survey of endocrinologists and financial data from Medicare. Patterns of use of resources were identified, annual costs for the surgical management of primary hyperparathyroidism in the United States were calculated, and the financial impact of variation in practice was estimated. RESULTS: Survey respondents (n = 109) were experienced endocrine surgeons, performing an average of 33 parathyroidectomies annually. Seventy-five percent of patients undergo localization before initial exploration for primary hyperparathyroidism. In order of preference, these studies were sestamibi (43%), ultrasonography (28%), and sestamibi with single-photon emission computed tomography (26%). Although there is variation in preoperative and postoperative practice, in-hospital costs have the greatest influence on total cost. An estimated $282 million is spent annually in the United States on operations for primary hyperparathyroidism. National health expenditures could range by more than $70 million, depending on whether management strategies involving low or high use of resources are employed. CONCLUSIONS: Substantial variation among endocrine surgeons in the management of primary hyperparathyroidism has important cost implications. Implementation of evidence-based guidelines to optimize clinical and economic performance should be considered.

Should hepatic resections be performed at high-volume referral centers?

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.

OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.

Importance of hospital volume in the overall management of pancreatic cancer.

OBJECTIVE: To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent. METHODS: Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume. RESULTS: Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively. CONCLUSIONS: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality.

OBJECTIVE: This study examined a statewide trend in Maryland toward regionalization of pancreaticoduodenectomy over a 12-year period and its effect on statewide in-hospital mortality rates for this procedure. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that the best outcomes are achieved in centers performing large numbers of pancreaticoduodenectomies, which suggests that regionalization could lower the overall in-hospital mortality rate for this procedure. METHODS: Maryland state hospital discharge data were used to select records of patients undergoing a pancreaticoduodenectomy between 1984 and 1995. Hospitals were classified into high-volume and low-volume provider groups. Trends in surgical volume and mortality rates were examined by provider group and for the entire state. Regression analyses were used to examine whether hospital share of pancreaticoduodenectomies was a significant predictor of the in-hospital mortality rate, adjusting for study year and patient characteristics. The portion of the decline in the statewide in-hospital mortality rate for this procedure attributable to the high-volume provider's increasing share was determined. RESULTS: A total of 795 pancreaticoduodenectomies were performed in Maryland at 43 hospitals from 1984 to 1995 (Maryland residents only). During this period, one institution increased its yearly share of pancreaticoduodenectomies from 20.7% to 58.5%, and the statewide in-hospital mortality rate for the procedure decreased from 17.2% to 4.9%. After adjustment for patient characteristics and study year, hospital share remained a significant predictor of mortality. An estimated 61% of the decline in the statewide in-hospital mortality rate for the procedure was attributable to the increase in share of discharges at the high-volume provider. CONCLUSIONS: A trend toward regionalization of pancreaticoduodenectomy over a 12-year period in Maryland was associated with a significant decrease in the statewide in-hospital mortality rate for this procedure, demonstrating the effectiveness of regionalization for high-risk surgery.

Resuscitation of the hypothermic patient.

A case of cardiac arrest following hypothermia due to cold-water immersion is presented. Following rescue and initiation of cardiopulmonary resuscitation, the patient was transported by helicopter to a facility where rewarming using cardiopulmonary bypass was possible. Initial rectal temperature in the emergency department was 28 degrees C. Initial prehospital rhythm was ventricular fibrillation persisting approximately 1.5 hours until the patient was successfully cardioverted after 25 minute of femoral artery/femoral venous partial cardiopulmonary bypass rewarming. Temperature at the time of cardioversion was 30 degrees C (esophageal). Despite extended cardiac arrest and profound metabolic acidosis (pH = 6.41 at 37 degrees C), he recovered uneventfully and is neurologically normal. A protocol for the management of a patient with hypothermic cardiac arrest is included.