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Background: Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. Objective: To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. Design: Retrospective cohort analysis of manually abstracted electronic medical records. Patients: 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 Main Measures: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). Key Results: Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9–1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6–1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). Conclusions: Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death. [ABSTRACT FROM AUTHOR]

Background: We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID‐19. Methods: This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID‐19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do‐not‐resuscitate [DNR] orders) and in‐hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%–20%, or high >20% ACP rates). Results: Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia‐biased ACP billing practices (risk‐adjusted ICU use: 21% vs. 30%, odds ratio [OR] = 0.6, p = 0.016; risk‐adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). Conclusions: Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID‐19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference‐sensitive" care for COVID‐19. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy.Data Sources: National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy.Study Design: Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy.Principal Findings: Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy.Conclusions: This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience. [ABSTRACT FROM AUTHOR]

The number of hospital COVID-19 patients was not associated with provider COVID-19 infections (<150 COVID-19 patients = 2.7% provider positive rate; 150-500 COVID-19 patients = 2.1% provider positive rate [OR 0.8, 95%CI 0.3-1.8, p=0.532]; >500 COVID-19 patients = 2.9% provider positive rate [OR 1.1, 95%CI 0.4-2.7, p=0.851]). The infection rate was 0.9% for providers who took care of <10 COVID-19 patients, 2.4% for providers caring for 10-49 COVID-19 patients (OR 2.7, 95%CI 1.1-6.8, p=0.037), and 4.1% for providers caring for 50+ COVID-19 patients (OR 4.8, 95%CI 1.8-12.9, p=0.002). These findings suggest that it is not the total number of COVID-19 patients hospitalized, which may reflect the number of COVID-19 patients in that hospital's community, but the number of COVID-19 patients that providers directly treat which increases the risk of virus transmission. [Extracted from the article]

Background. With nearly 53 million ambulatory procedures performed annually, future efforts to achieve greater value in surgical care should include a focus on outpatient surgery. To inform such efforts, a better understanding of specialty-specific trends in outpatient surgery is required. Objectives. To assess the prevalence and distribution of outpatient surgery across specialties. Research design. Repeated cross-sectional. Measures. Using all-payer data from Florida (1998-2008), we identified physicians who performed one or more procedures. We assigned a specialty to each physician based on his procedure mix. After measuring the proportion of procedures performed on an outpatient basis, we assessed for specialty-specific changes over time in this proportion. Finally, we determined the frequency with which individual specialties used surgery centers for their outpatient care. Results. More than two thirds (67.8%) of all surgical procedures are carried out on an outpatient basis. The popularity of outpatient surgery has grown among many specialties over the past decade, including several (urology, gastroenterology, plastic surgery, and ophthalmology) that perform most of their cases in outpatient settings. Within surgical disciplines, overall trends in the use of outpatient surgery are strongly associated with the specialty’s affinity for freestanding ambulatory surgery centers (Pearson’s correlation coefficient = 0.76; P < .001). Conclusions. A majority of surgeons in many specialties now provide predominantly outpatient care. Incorporating these findings into the design of future payment and delivery system reforms will help ensure adequate surgeon exposure to the efficiency gains that evolve from them. [ABSTRACT FROM PUBLISHER]

The article focuses on a retrospective, longitudinal study using hospital discharge data from 12 states of the U.S. for Medicare patients undergoing bariatric surgery from 2004-2009. The objective of this study is to evaluate whether the implementation of the centers of excellence (COE) component of the U.S. national coverage decision associated with the Centers for Medicare & Medicaid Services' restriction regarding coverage of bariatric surgery to hospitals designated as COE, has resulted in improvement of bariatric surgery outcomes in Medicare patients. It mentions that among the Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and re-operation before and after the regulation came into effect.

Objective: To evaluate the effectiveness and safety of 3 predominant venous thromboembolism (VTE) prophylaxis strategies among patients undergoing bariatric surgery. Design: Cohort study. Setting: The Michigan Bariatric Surgery Collaborative, a statewide clinical registry and quality improvement program. Patients: Twenty-four thousand seven hundred seventy seven patients undergoing bariatric surgery between 2007 and 2012. Interventions: Unfractionated heparin preoperatively and postoperatively (UF/UF), UF heparin preoperatively and low-molecular-weight heparin postoperatively (UF/LMW), and LMW heparin preoperatively and postoperatively (LMW/LMW). Main Outcome Measures: Rates of VTE, hemorrhage, and serious hemorrhage (requiring >4U of blood products or reoperation) occurring within 30 days of surgery. Results: Overall, adjusted rates of VTE were significantly lower for the LMW/LMW (0.25%; P<.001) and UF/LMW (0.29%; P=.03) treatment groups compared with the UF/UF group (0.68%). While UF/LMW (0.22%; P=.006) and LMW/LMW (0.21%; P<.001) were similarly effective in patients at low risk of VTE (predicted risk<1%), LMW/LMW (1.46%; P=.10) seemed more effective than UF/LMW (2.36%; P=.90) for high-risk (predicted risk ⩾1%) patients. There were no significant differences in rates of hemorrhage or serious hemorrhage among the treatment strategies. Conclusion: Low-molecular-weight heparin is more effective than UF heparin for the prevention of postoperative VTE among patients undergoing bariatric surgery and does not increase rates of bleeding. [ABSTRACT FROM AUTHOR]

Objective To assess the value of a novel composite measure for identifying the best hospitals for major procedures. Data Source We used national Medicare data for patients undergoing five high-risk surgical procedures between 2005 and 2008. Study Design For each procedure, we used empirical Bayes techniques to create a composite measure combining hospital volume, risk-adjusted mortality with the procedure of interest, risk-adjusted mortality with other related procedures, and other variables. Hospitals were ranked based on 2005-2006 data and placed in one of three groups: 1-star (bottom 20 percent), 2-star (middle 60 percent), and 3-star (top 20 percent). We assessed how well these ratings forecasted risk-adjusted mortality rates in the next 2 years (2007-2008), compared to other measures. Principal Findings For all five procedures, the composite measures based on 2005-2006 data performed well in predicting future hospital performance. Compared to 1-star hospitals, risk-adjusted mortality was much lower at 3-star hospitals for esophagectomy (6.7 versus 14.4 percent), pancreatectomy (4.7 versus 9.2 percent), coronary artery bypass surgery (2.6 versus 5.0 percent), aortic valve replacement (4.5 versus 8.5 percent), and percutaneous coronary interventions (2.4 versus 4.1 percent). Compared to individual surgical quality measures, the composite measures were better at forecasting future risk-adjusted mortality. These measures also outperformed the Center for Medicare and Medicaid Services ( CMS) Hospital Compare ratings. Conclusion Composite measures of surgical quality are very effective at predicting hospital mortality rates with major procedures. Such measures would be more informative than existing quality indicators in helping patients and payers identify high-quality hospitals with specific procedures. [ABSTRACT FROM AUTHOR]

Background: Distal radial fractures affect an estimated 80,000 elderly Americans each year. Although the use of internal fixation for the treatment of distal radial fractures is becoming increasingly common, there have been no population-based studies to explore the dissemination of this technique. The aims of our study were to determine the current use of internal fixation for the treatment of distal radial fractures in the Medicare population and to examine regional variations and other factors that influence use of this treatment. We hypothesized that internal fixation of distal radial fractures would be used less commonly in male and black populations compared with other populations because the prevalence of osteoporosis is lower in these populations, and that use of internal fixation would be correlated with the percentage of the patients who were treated by a hand surgeon in a particular region. Methods: We performed an analysis of complete 2007 Medicare data to determine the percentage of distal radial fractures that were treated with internal fixation in each hospital referral region. We then analyzed the association of patient and physician factors with the type of fracture treatment received, both nationally and within each hospital referral region. Results: We identified 85,924 Medicare beneficiaries with a closed distal radial fracture who met the inclusion criteria, and 17.0% of these patients were treated with internal fixation. Fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio, 0.84; 95% confidence interval, 0.80 to 0.89) and in black patients than in white patients (odds ratio, 0.74; 95% confidence interval, 0.65 to 0.85). Patients were more likely to be treated with internal fixation rather than with another treatment if they were treated by a hand surgeon than if they were treated by an orthopaedic surgeon who was not a hand surgeon (odds ratio, 2.49; 95% confidence interval, 2.29 to 2.70). Use of internal fixation ranged from 4.6% to 42.1% (nearly a ten-fold difference) among hospital referral regions. The percentage of patients treated with internal fixation within a hospital referral region was positively correlated with the percentage of patients in that region who were treated by a hand surgeon (correlation coefficient, 0.34; p < 0.0001). Conclusions: The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture. [ABSTRACT FROM AUTHOR]

The article discusses a study on outcomes of carotid stenting based on operator experience in the U.S. from 2005 to 2007. The study evaluated the link between outcomes and two variables of operator experience, namely, annual volume and experience at the time of the procedure among new operators who performed carotid stenting for the first time following a national coverage decision by the Centers for Medicare & Medicaid Services (CMS). Administrative data collected from fee-for-service Medicare beneficiaries aged 65 years old and above was used under the study. Higher 30-day mortality was observed among patients treated by operators with lower annual volumes and patients treated early during a new operator's experience.

The article focuses on a study on the practice patterns of hospitals regarding the use of radioactive iodine for treating thyroid cancer. It is said that radioactive iodine use tend to depend at the discretion of the physician due to the lack of randomized controlled trials that evaluate the utility of the medication relative to the severity of the disease. Results show that radioactive iodine for thyroid cancer treatment increased across all tumor sizes between 1990 to 2008 while hospital use of such medication is said to vary due to unexplained hospital characteristics. Findings indicate that radioactive iodine use is influenced by other factors aside from disease severity.

Relative to outpatient surgery in hospital settings, ambulatory surgery centers (ASCs) are more efficient and associated with a lower cost per case. However, these facilities may also spur higher overall procedure utilization and thus lead to greater overall health care costs. The authors used the State Ambulatory Surgery Database from the State of Florida to identify Medicare-aged patients undergoing 4 common ambulatory procedures in 2006, including knee arthroscopy, cystoscopy, cataract removal, and colonoscopy. Hospital service areas (HSAs) were characterized according to ASC market share, that is, the proportion of residents undergoing outpatient surgery in these facilities. The authors then examined relationships between ASC market share and rates of each procedure. Age-adjusted rates of ambulatory surgery ranged from 190.5 cases per 1000 to 320.8 cases per 1000 in HSAs with low and high ASC market shares, respectively (P < .01). For all 4 procedures, adjusted rates of procedures were significantly higher in HSAs with the highest ASC market share. The greatest difference, both in relative and absolute terms, was observed for patients undergoing cystoscopy. In areas of high ASC market share, the age-adjusted rate of cystoscopy was nearly 3-fold higher than in areas with low ASC market share (34.5 vs 11.9 per 1000 population; P < .01). The presence of an ASC is associated with higher utilization of common outpatient procedures in the elderly. Whether ASCs are meeting unmet clinical demand or spurring overutilization is not clear. [ABSTRACT FROM PUBLISHER]

Objective: We examined the implications of reliability adjustment on hospital mortality with surgery.Data Source: We used national Medicare data (2003-2006) for three surgical procedures: coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, and pancreatic resection.Study Design: We conducted an observational study to evaluate the impact of reliability adjustment on hospital mortality rankings. Using hierarchical modeling, we adjusted hospital mortality for reliability using empirical Bayes techniques. We assessed the implication of this adjustment on the apparent variation across hospitals and the ability of historical hospital mortality rates (2003-2004) to forecast future mortality (2005-2006).Principal Findings: The net effect of reliability adjustment was to greatly diminish apparent variation for all three operations. Reliability adjustment was also particularly important for identifying hospitals with the lowest future mortality. Without reliability adjustment, hospitals in the "best" quintile (2003-2004) with pancreatic resection had a mortality of 7.6 percent in 2005-2006; with reliability adjustment, the "best" hospital quintile had a mortality of 2.7 percent in 2005-2006. For AAA repair, reliability adjustment also improved the ability to identify hospitals with lower future mortality. For CABG, the benefits of reliability adjustment were limited to the lowest volume hospitals.Conclusion: Reliability adjustment results in more stable estimates of mortality that better forecast future performance. This statistical technique is crucial for helping patients select the best hospitals for specific procedures, particularly uncommon ones, and should be used for public reporting of hospital mortality. [ABSTRACT FROM AUTHOR]

Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals. Using the national Medicare database, we identified patients undergoing one of four inpatient procedures in 2005 (coronary artery bypass [CABG], hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days postdischarge were assessed and categorized by payment type (hospital, physician, and postacute care) and subtype. Average total payments for inpatient surgery episodes varied from U.S.$26,515 for back surgery to U.S.$45,358 for CABG. Hospital payments accounted for the largest share of total payments (60-80 percent, depending on procedure), followed by physician payments (13-19 percent) and postacute care (7-27 percent). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by U.S.$16,668 for CABG, U.S.$18,762 for back surgery, U.S.$10,615 for hip fracture repair, and U.S.$12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions and postacute care varied most substantially across hospitals. Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments-both overall and for specific services-vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency. [ABSTRACT FROM AUTHOR]

We examined the implications of reliability adjustment on hospital mortality with surgery. We used national Medicare data (2003-2006) for three surgical procedures: coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, and pancreatic resection. We conducted an observational study to evaluate the impact of reliability adjustment on hospital mortality rankings. Using hierarchical modeling, we adjusted hospital mortality for reliability using empirical Bayes techniques. We assessed the implication of this adjustment on the apparent variation across hospitals and the ability of historical hospital mortality rates (2003-2004) to forecast future mortality (2005-2006). The net effect of reliability adjustment was to greatly diminish apparent variation for all three operations. Reliability adjustment was also particularly important for identifying hospitals with the lowest future mortality. Without reliability adjustment, hospitals in the 'best' quintile (2003-2004) with pancreatic resection had a mortality of 7.6 percent in 2005-2006; with reliability adjustment, the 'best' hospital quintile had a mortality of 2.7 percent in 2005-2006. For AAA repair, reliability adjustment also improved the ability to identify hospitals with lower future mortality. For CABG, the benefits of reliability adjustment were limited to the lowest volume hospitals. Reliability adjustment results in more stable estimates of mortality that better forecast future performance. This statistical technique is crucial for helping patients select the best hospitals for specific procedures, particularly uncommon ones, and should be used for public reporting of hospital mortality. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether high rates of compliance with perioperative processes of care used for public reporting and pay-for-performance are associated with lower rates of risk-adjusted mortality and high-risk surgical complications. Design: Retrospective analysis of Medicare inpatient claims data (from January 1, 2005, through December 31, 2006). Hierarchical logistic regression models assessed the relationship between adverse outcomes and hospital compliance with the surgical processes of care reported on the Hospital Compare Web site. Setting: Two thousand US hospitals. Participants: Beneficiaries who underwent 1 of 6 highrisk operations in 2005 and 2006. Main Outcome Measures: Thirty-day postoperative mortality rate, venous thromboembolism, and surgical site infection. Results: Process compliance ranged from 53.7% in low compliance hospitals to 91.4% in high compliance hospitals. Risk-adjusted outcomes did not vary at high compliance hospitals relative to medium compliance hospitals for mortality rate (odds ratio, 0.98; 95% confidence interval, 0.92-1.05), surgical site infection (1.01; 0.90- 1.13), or venous thromboembolism (1.04; 0.89-1.20). Outcomes also did not vary at low compliance hospitals. Stratified analyses by operation type confirm these trends for the 6 procedures individually. Conclusions: Currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery. The Centers for Medicare and Medicaid Services needs to identify higher leverage process measures and devote greater attention to profiling hospitals based on outcomes to improve public reporting and pay-for-performance efforts. [ABSTRACT FROM AUTHOR]

Background: Surgical quality improvement has received increasing attention in recent years, but it is not clear where orthopaedic surgeons should focus their efforts for the greatest impact on perioperative safety and quality. We sought to guide these efforts by prioritizing orthopaedic procedures according to those that generate the greatest number of adverse events. Methods: We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify all patients who had undergone an orthopaedic surgical procedure between 2005 and 2007 (n = 7970). Patients were assigned to forty-four unique procedure groups on the basis of the Current Procedural Terminology (CPT) codes. We first assessed the relative contribution of each procedure group to the overall number of adverse events in the first thirty postoperative days, and we followed that with a description of their relative contribution to an excess length of stay in the hospital. Results: Ten procedures accounted for 70% of the adverse events and 65% of the excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femoral fracture repair. No other procedure group accounted for >2% of the adverse events. Conclusions: Only a few procedures account for the vast majority of adverse events in the first thirty days following orthopaedic surgery. Concentrating quality-improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve perioperative care and reduce costs in orthopaedic surgery. [ABSTRACT FROM AUTHOR]

The article discusses medical research with emphasis on the assessment of complication rates of different bariatric surgery in hospitals in Michigan. It states that the research involves the assessment of bariatric surgery complications in 25 hospitals and 62 surgeons in Michigan Bariatric Surgery Collaborative (MBSC). It mentions that there is 7.3% of patients who experienced perioperative complications overall. It concludes that complication rates of different bariatric surgery in hospitals in Michigan was relatively low.

The article presents a study which examines the racial disparities in treatment and outcomes in patients with early stage bladder cancer. The patients were identified using Medicare data from 1999 to 2002. It says that differences in initial treatment found by the study have unclear clinical significance. It adds that the disparity in which black patients are at greater risk of death than white patients, does not appear to be caused by differences in the quality and intensity of care provided.