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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 [...]

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. Key Words. Administrative data uses, econometrics, modeling, multi-level, risk adjustment for clinical outcomes, quality of care/patient safety (measurement), With wide recognition that surgical outcomes vary across hospitals, information on surgical quality is in high demand. Patients, families, and referring physicians are looking for information to help them select [...]

Background. 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. Study Design. 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. Results. 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. Conclusions. 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. Key Words. Surgery, Medicare, bundled payments, Efforts to curb the growth of health care spending in the United States, widely considered a national priority, will inevitably involve surgery. Extrapolating from our analyses of national Medicare data, [...]

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. Key Words. Quality, surgery, hospital, mortality, hierarchical, Surgical mortality rates are used widely to measure quality with high-risk surgery. New York, Pennsylvania, California, and a growing number of other states publicly report hospital mortality rates for cardiac [...]

Background Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes. Methods We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided. Results The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High-treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low-treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low--vs high-treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high--treatment intensity providers than by low--treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02). Conclusions Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high-treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.

Background Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists. Methods We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly ([greater than or equal to] 66 years of age) patients who had been hospitalized for resection of stage II or Ill rectal cancer (n = 2716). We used [chi square] tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided. Results There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = -5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = -0.5% to 16.7%, P= .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. Conclusion Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

The risk for viral transmission by transfusion has been reduced dramatically through improved techniques for selecting and testing blood donors. Initiatives to further improve the safety of the blood supply, including more stringent donor qualifications, additional testing for infectious disease markers, viral inactivation processes, and refinement of transfusion decisions, are possible. However, because the risk for viral transmission by allogeneic transfusion is already low, additional measures will have limited yield and poor cost-effectiveness. Furthermore, unexpected side effects of some of these 'improvements' may reduce the safety of the blood supply by introducing new risks. Cost-effectiveness analyses of blood safety initiatives have highlighted such successes as the introduction of virus-specific assays for screening donated blood and have identified other interventions that have poor cost-effectiveness estimates. They have also quantitated the threshold level at which the risks of an intervention outweigh its benefits. These analyses have had little effect on decisions about blood safety, possibly because of overwhelming fear of AIDS and difficulties in applying cost-effectiveness estimates to a politically and emotionally charged issue. Future interventions for improving blood supply safety must be evaluated thoroughly and chosen carefully so that the intended goals are met. Communication with the public should be undertaken so that the public understands that some of the desired measures may result in inefficient allocation of health care resources., Additional measures to increase blood supply safety could paradoxically lead to increased risks, as well as a poor allocation of health-care resources. More stringent donor qualifications, more sensitive viral detection methods, and viral inactivation techniques carry their own risks. The point at which the risk exceeds the potential benefit can be seen in cost-effectiveness studies of these interventions. However, such analyses does not take into account emotional influences, such as the fear of HIV infection, that appear to be directing the push toward a zero-risk blood supply.

Objective: To estimate the cost-effectiveness of CT for detecting brain lesions in patients with lung cancer without clinical evidence of metastases. Design: Decision analysis model comparing two different strategies for [...]

Background: There are no studies that define the basic epidemiology of pulmonary embolism (PE) and deep venous thrombosis (DVT) in the elderly. This project was undertaken to provide that information. Methods: We obtained all Medicare claims during the period 1986 through 1989 from a random 5% sample of US Medicare enrollees. By selecting codes used for diagnoses and treatment, we identified 7174 cases of PE and 8923 cases of DVT. These cohorts were analyzed to provide incidence by age, race, sex, and geographic location; frequency of invasive treatment; frequency of PE after treatment for DVT; frequency of recurrence of PE; and survival after diagnosis. Results: Annual incidence rates per 1000 at age 65 to 69 years for PE and DVT were 1.3 and 1.8, respectively. Both rates increased steadily with age to 2.8 and 3.1 by age 85 to 89 years. For PE, women had lower rates than men (adjusted relative risk, 0.86; 95% confidence interval, 0.82 to 0.90), and blacks had higher rates than whites (adjusted relative risk, 1.25; 95% confidence interval, 1.15 to 1.36). For DVT, the associations with gender and race were weaker and in the opposite direction. Pulmonary embolectomy was done in 0.2% of cases of PE; interruption of the vena cava was done in 4.4% of cases of PE and in 2% of cases of DVT. Thrombectomy was done in 0.3% of all cases. Pulmonary embolism occurred in 1.7% of patients with DVT within I year of hospital discharge for initial treatment. The 1-year recurrence rate for PE was 8.0%. In-hospital mortality associated with PE and DVT was 21% and 3%, respectively. One-year mortality was 39% and 21%. respectively. Conclusions: Pulmonary embolism and DVT are common problems in the elderly. Both increase with age, but the effects of race and sex are small. Current treatment patterns appear to be effective in preventing both PE after DVT and recurrence of PE. Both are associated with substantial 1-year mortality, suggesting the need to understand the role of associated conditions as well as the indications for prophylaxis and the methods of treatment.

* Objective: To compare the relative risks and benefits of several clinical strategies for managing patients with chronic atrial fibrillation. * Design: Five recent randomized controlled trials of warfarin in atrial fibrillation, 6 randomized controlled trials of quinidine, and 13 longitudinal studies of low-dose amiodarone were used. A MEDLINE search was also done (1966 to present). * Measurements: A Markov decision analysis model was used to assess outcomes in large, hypothetical cohorts of patients with atrial fibrillation followed from 65 to 70 years of age within four clinical strategies: 1) no treatment; 2) warfarin; 3) electrical cardioversion followed by quinidine to maintain normal sinus rhythm; and 4) electrical cardioversion followed by low-dose amiodarone. * Results: In this hypothetical cohort, fewer patients had disabling events with amiodarone (1.4%) than with quinidine (1.8%), warfarin (2.6%), or no treatment (7.4%). Amiodarone appeared to be associated with the lowest 5-year mortality (13.6%) when compared with warfarin (14.4%), quinidine (15.2%), and no treatment (18.2%). In terms of quality-adjusted life-years, amiodarone had the highest expected value (4.75 years), followed by warfarin (4.72 years), quinidine (4.68 years), and no treatment (4.55 years). Amiodarone remained the preferred strategy using the most plausible scenarios of risks associated with atrial fibrillation. Choices among warfarin, quinidine, and no treatment depended on estimates of bleeding rates with warfarin, stroke rates after discontinuing warfarin, quinidine-related mortality, and the quality of life with warfarin. * Conclusion: Cardioversion followed by low-dose amiodarone to maintain normal sinus rhythm appears to be a relatively safe and effective treatment for patients with chronic atrial fibrillation., Cardioversion and low-dose amiodarone may be an effective treatment for chronic atrial fibrillation. Atrial fibrillation is the rapid, random contraction of individual fibers of the heart muscle causing an irregular, rapid heart beat. Cardioversion is used to restore the normal rhythm of the heart by electrical shock. Researchers applied a decision analysis model to a hypothetical set of patients based on the patients of 24 studies. They evaluated the efficacy of no treatment, warfarin, cardioversion followed by quinidine and cardioversion followed by low-dose amiodarone. Among the hypothetical patients, 1.4% had disabling cardiac events with amiodarone, compared to 1.8% with quinidine, 2.6% with warfarin and 7.4% with no treatment. Amiodarone was also associated with the lowest five-year mortality rate (13.6%) and the highest expected value for quality-adjusted life years (4.75 years) when compared to the other treatments.

PURPOSE: In addition to historically important issues of blood inventory and blood safety, the costs of blood transfusion are anticipated to have an increasingly important impact on transfusion practices. To address this, we analyzed costs of blood support given to patients undergoing coronary artery bypass graft (CABG) surgery, along with costs of blood components whose transfusions were identified to be unnecessary. PATIENTS AND METHODS: Blood components transfused as part of a previously reported national, multicenter audit of 30 adult patients each at 18 institutions undergoing primary, elective CABG surgery were reviewed. RESULTS: The range of blood purchase costs among institutions was broad, varying over two-fold. The range of red cell units transfused varied over 10-fold, and the range of total components transfused varied over 40-fold. The number of blood components transfused unnecessarily represented 27% of all blood units transfused, ranging from 7% to 43% among institutions. Inappropriate transfusions accounted for 47%, 32%, and 15% of all platelet, plasma, and red cell units transfused. The mean institutional cost for all blood components transfused per patient was $397 [+ or -] $244. The cost per patient of components transfused inappropriately was 24% of this, or $96 [+ or -] $89 (mean [+ or -] SD). CONCLUSION: These costs could be reduced with practice guidelines and quality improvement programs aimed at reducing the number of inappropriate transfusions.

Background: Although guidelines recommend angiotensin-converting enzyme inhibitors for diabetic patients with microalbuminuria, this strategy requires that providers adhere to screening recommendations. In addition, the benefit of angiotensin-converting enzyme inhibitors in normoalbuminuric patients was recently demonstrated. Objective: To evaluate the cost-effectiveness of treating all patients with type 2 diabetes. Design: Markov model simulating the progression of diabetic nephropathy. Data Sources: Randomized trials estimating the progression of diabetic nephropathy with and without angiotensin-converting enzyme inhibitors. Target Population: Patients 50 years of age with newly diagnosed type 2 diabetes (fasting plasma glucose level [is greater than or equal to] 7.8 mmol/L [140 mg/dL]). Time Horizon: Lifetime. Perspective: Societal. Interventions: Patients received angiotensin-converting enzyme inhibitors, screening for microalbuminuria, or screening for gross proteinuria. Outcome Measures: Lifetime cost, quality-adjusted life expectancy, and marginal cost-effectiveness. Results of Base-Case Analysis: Screening for gross proteinuria had the highest cost and the lowest benefit. Compared with screening for microalbuminuria, treating all patients was more expensive ($15 240 and $14940 per patient) but was associated with increased quality-adjusted life expectancy (11.82 and 11.78 quality-adjusted life-years). The marginal cost-effectiveness ratio was $7500 per quality-adjusted life-year gained. Results of Sensitivity Analysis: Results were sensitive to the cost, effectiveness, and quality of life associated with angiotensin-converting enzyme inhibitor therapy, as well as age at diagnosis. The model was relatively insensitive to adherence with screening and costs of treating end-stage renal disease. Conclusions: Treating all middle-aged diabetic patients with angiotensin-converting enzyme inhibitors is a simple strategy that provides additional benefit at modest additional cost. The strategy assumes that patients meet the older diagnostic criteria for diabetes and makes sense only for those who are not bothered by treatment., Treating all middle-aged patients with type 2 diabetes using angiotensin-converting enzyme (ACE) inhibitors is a simple cost-effective strategy that provides additional benefit, provided that screening recommendations are followed. This study was done with randomized trials estimating the progression of kidney disease with and without ACE inhibitors to determine lifetime cost, life expectancy, and cost-effectiveness. Screening for protein in the urine had the highest cost and the lowest benefit. Compared against the cost of screening for microalbuminuria, treating all patients was more expensive, but was associated with increased quality-adjusted life expectancy. The marginal cost-effectiveness ratio was $7500 per quality-adjusted life-year gained.

Background: Physicians managing patients with nonvalvular atrial fibrillation must consider the risks, benefits, and costs of treatments designed to restore and maintain sinus rhythm compared with those of rate control with antithrombotic prophylaxis. Objective: To compare the cost-effectiveness of cardioversion, with or without antiarrhythmic agents, with that of rate control plus warfarin or aspirin. Design: A Markov decision-analytic model was designed to simulate long-term health and economic outcomes. Data Sources: Published literature and hospital accounting information. Target Population: Hypothetical cohort of 70-year-old patients with different baseline risks for stroke. Time Horizon: 3 months. Perspective: Societal. Intervention: Therapeutic strategies using different combinations of cardioversion alone, cardioversion plus amiodarone or quinidine therapy, and rate control with antithrombotic treatment. Outcome Measures: Expected costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness. Results of Base-Case Analysis: Strategies involving cardioversion alone were more effective and less costly than those not involving this option. For patients at high risk for ischemic stroke (5.3% per year), cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse was most cost-effective ($9300 per QALY) compared with cardioversion alone followed by warfarin therapy on relapse. This strategy was also preferred for the moderate-risk cohort (3.6% per year), but the benefit was more expensive ($18 900 per QALY). In the lowest-risk cohort (1.6% per year), cardioversion alone followed by aspirin therapy on relapse was optimal. Results of Sensitivity Analysis: The choice of optimal strategy and incremental cost-effectiveness was substantially influenced by the baseline risk for stroke, rate of stroke in sinus rhythm, efficacy of warfarin, and costs and utilities for long-term warfarin and amiodarone therapy. Conclusions: Cardioversion alone should be the initial management strategy for persistent nonvalvular atrial fibrillation. On relapse of arrhythmia, repeated cardioversion plus low-dose amiodarone is cost-effective for patients at moderate to high risk for ischemic stroke., Restoration of a normal heart rhythm, plus treatment with antiarrhythmic drugs or aspirin, most effectively reduce the risk of stroke in patients with nonvalvular atrial fibrillation. Atrial fibrillation is a disordered rhythm of the upper chambers of the heart. Researchers compared treatments for a hypothetical group of 70-year-old patients with the arrhythmia. Cardioversion, or the restoration of a normal sinus rhythm with an electric shock, was the most cost-effective treatment for all patients. Depending on the risk of stroke, patients may then benefit from drug therapy with amiodarone or aspirin to control the arrhythmia and reduce the formation of blood clots.