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IMPORTANCE: Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care. OBJECTIVES: To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims. EXPOSURES: Admission to a PSC. MAIN OUTCOMES AND MEASURES: Seven-day and 30-day postadmission case-fatality rates. RESULTS: Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, −2.1% to −1.4%) lower 7-day and 1.8% (95% CI, −2.3% to −1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care. CONCLUSIONS AND RELEVANCE: Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.

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IMPORTANCE: Wide variations in mortality rates exist across hospitals following lung cancer resection; however, the factors underlying these differences remain unclear. OBJECTIVE: To evaluate perioperative outcomes in patients who underwent lung cancer resection at hospitals with very high and very low mortality rates (high-mortality hospitals [HMHs] and low-mortality hospitals [LMHs]) to better understand the factors related to differences in mortality rates after lung cancer resection. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, 1279 hospitals that were accredited by the Commission on Cancer were ranked on a composite measure of risk-adjusted mortality following major cancer resections performed from January 1, 2005, through December 31, 2006. We collected data from January 1, 2006, through December 31, 2007, on 645 lung resections in 18 LMHs and 25 HMHs. After adjusting for patient characteristics, we used hierarchical logistic regression to examine differences in the incidence of complications and “failure-to-rescue” rates (defined as death following a complication). MAIN OUTCOMES AND MEASURES: Rates of adherence to processes of care, incidence of complications, and failure to rescue following complications. RESULTS: Among 645 patients who received lung resections (441 in LMHs and 204 in HMHs), the overall unadjusted mortality rates were 1.6% (n = 7) vs 10.8% (n = 22; P < .001) for LMHs and HMHs, respectively. Following risk adjustment, the difference in mortality rates was attenuated (1.8% vs 8.1%; P < .001) but remained significant. Overall, complication rates were higher in HMHs (23.3% vs 15.6%; adjusted odds ratio [aOR], 1.79; 95% CI, 0.99-3.21), but this difference was not significant. The likelihood of any surgical (aOR, 0.73; 95% CI, 0.26-2.00) or cardiopulmonary (aOR, 1.23; 95% CI, 0.70-2.16) complications was similar between LMHs and HMHs. However, failure-to-rescue rates were significantly higher in HMHs (25.9% vs 8.7%; aOR, 6.55; 95% CI, 1.44-29.88). CONCLUSIONS AND RELEVANCE: Failure-to-rescue rates are higher at HMHs, which may explain the large differences between hospitals in mortality rates following lung cancer resection. This finding emphasizes the need for better understanding of the factors related to complications and their subsequent management.

This was a retrospective study using Medicare data to quantify the financial impact of surgical quality improvement. We identified a strong temporal relationship between quality improvement and reduced Medicare payments, strengthening the business case for investment in quality improvement initiatives.

Supplemental Digital Content is Available in the Text.This study evaluates the correlation between time-to-readmission and postdischarge mortality in surgical patients. Independent of complications during the index hospitalization, we found a stepwise decrease in mortality as time-to-readmission increased. Our findings imply that readmissions within 10 days should be specially targeted by quality improvement efforts.

This is a national cohort study of cancer surgery at 49 very low or very high mortality hospitals. The overall incidence of complications was not different between hospital groups, but case-fatality after complications was more than threefold higher. These hospitals are distinguished less by their complication rates than by how frequently patients die after a complication (so-called “failure to rescue”).

Compared with white patients, black patients are more likely to undergo cardiac surgery at low-quality hospitals, even when they live closer to high-quality ones. Opportunities for organizational interventions to alleviate this problem remain elusive.

There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization.

IMPORTANCE: Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. OBJECTIVE: To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. DESIGN, SETTING, AND PARTICIPANTS: Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. MAIN OUTCOMES AND MEASURES: Number of inpatient medical consultations. RESULTS: More than half of patients undergoing colectomy (91 684) or THR (339 319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. CONCLUSIONS AND RELEVANCE: The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.

To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States.

IMPORTANCE To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. OBJECTIVE To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications. DESIGN, SETTING, AND PARTICIPANTS We used patient-level data from 119 434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile. EXPOSURE Hospital procedural volume. MAIN OUTCOMES AND MEASURES Hospital rates of risk-adjusted mortality, major complications, and failure to rescue. RESULTS For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred. CONCLUSIONS AND RELEVANCE High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.

IMPORTANCE Although lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear. OBJECTIVE To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral arterial disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 18 463 US Medicare patients who underwent a major peripheral arterial disease–related amputation during the period between 2003 and 2010. EXPOSURE Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions. MAIN OUTCOMES AND MEASURES Correlation coefficient between regional spending on vascular care and regional rates of peripheral arterial disease–related amputation. RESULTS Among patients who ultimately underwent an amputation, 64% were admitted to the hospital in the year prior to the amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including costs related to the amputation procedure itself, was $22 405, but it varied from $11 077 (Bismarck, North Dakota) to $42 613 (Salinas, California) (P < .001). Patients in high-spending regions were more likely to undergo vascular procedures as determined by crude analyses (12.0 procedures per 10 000 patients in the lowest quintile of spending and 20.4 procedures per 10 000 patients in the highest quintile of spending; P < .001) and by risk-adjusted analyses (adjusted odds ratio for receiving a vascular procedure in highest quintile of spending, 3.5 [95% CI, 3.2-3.8]; P < .001). Although revascularization was associated with higher spending (R = 0.38, P < .001), higher spending was not associated with lower regional amputation rates (R = 0.10, P = .06). The regions that were most aggressive in the use of endovascular interventions were the regions that were most likely to have high spending (R = 0.42, P = .002) and high amputation rates (R = 0.40, P = .004). CONCLUSIONS AND RELEVANCE Regions that spend the most on vascular care perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.

IMPORTANCE The optimal approach for profiling hospital performance with bariatric surgery is unclear. OBJECTIVE To develop a novel composite measure for profiling hospital performance with bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS Using clinical registry data from the Michigan Bariatric Surgery Collaborative, we studied all patients undergoing bariatric surgery from January 1, 2008, through December 31, 2010. For laparoscopic gastric bypass surgery, we used empirical Bayes techniques to create a composite measure by combining several measures, including serious complications, reoperations, and readmissions; hospital and surgeon volume; and outcomes with other related procedures. Hospitals were ranked for 2008 through 2009 and placed in 1 of 3 groups: 3-star (top 20%), 2-star (middle 60%), and 1-star (bottom 20%). We assessed how well these ratings predicted outcomes in the next year (2010) compared with other widely used measures. MAIN OUTCOMES AND MEASURES Risk-adjusted serious complications. RESULTS Composite measures explained a larger proportion of hospital-level variation in serious complication rates with laparoscopic gastric bypass than other measures. For example, the composite measure explained 89% of the variation compared with only 28% for risk-adjusted complication rates alone. Composite measures also appeared better at predicting future performance compared with individual measures. When ranked on the composite measure, 1-star hospitals had 2-fold higher serious complication rates (4.6% vs 2.4%; odds ratio, 2.0; 95% CI, 1.1-3.5) compared with 3-star hospitals. Differences in serious complication rates between 1- and 3-star hospitals were much smaller when hospitals were ranked using serious complications (4.0% vs 2.7%; odds ratio, 1.6; 95% CI, 0.8-2.9) and hospital volume (3.3% vs 3.2%; odds ratio, 0.85; 95% CI, 0.4-1.7). CONCLUSIONS AND RELEVANCE Composite measures are much better at explaining hospital-level variation in serious complications and predicting future performance than other approaches. In this preliminary study, it appears that such composite measures may be better than existing alternatives for profiling hospital performance with bariatric surgery.

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

The use of common surgical procedures varies widely across regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain only a small degree of regional variation in surgery rates. Evidence suggests that surgical variation results mainly from differences in physician beliefs about the indications for surgery, and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help to explain the so-called surgical signatures of specific procedures, and why some consistently vary more than others. Variation in clinical decision making is, in turn, affected by broad environmental factors, including technology diffusion, supply of specialists, local training frameworks, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions could help to mitigate regional variation, but broader dissemination of shared decision aids will be essential to reduce variation in preference-sensitive disorders.

Public reporting on quality aims to help patients select better hospitals. However, individual quality measures are suboptimal in identifying superior and inferior hospitals based on outcome performance.

IMPORTANCE Much of the enthusiasm for accountable care organizations is fueled by evidence that integrated delivery systems (IDSs) perform better on measures of quality and cost in the ambulatory care setting; however, the benefits of this model are less clear for complex hospital-based care. OBJECTIVE To assess whether existing IDSs are associated with improved quality and lower costs for episodes of inpatient surgery. DESIGN, SETTING, AND PATIENTS We used national Medicare data (January 1, 2005, through November 30, 2007) to compare the quality and cost of inpatient surgery among patients undergoing coronary artery bypass grafting, hip replacement, back surgery, or colectomy in IDS-affiliated hospitals compared with those treated in a matched group of non–IDS-affiliated centers. MAIN OUTCOME MEASURES Operative mortality, postoperative complications, readmissions, and total and component surgical episode costs. RESULTS Patients treated in IDS hospitals differed according to several characteristics, including race, admission acuity, and comorbidity. For each of the 4 procedures, adjusted rates for operative mortality, complications, and readmissions were similar for patients treated in IDS-affiliated compared with non–IDS-affiliated hospitals, with the exception that those treated in IDS-affiliated hospitals had fewer readmissions after colectomy (12.6% vs 13.5%, P = .03). Adjusted total episode payments for hip replacement were 4% lower in IDS-affiliated hospitals (P < .001), with this difference explained mainly by lower expenditures for postdischarge care. Episode payments differed by 1% or less for the remaining procedures. CONCLUSIONS The benefits of the IDSs observed for ambulatory care may not extend to inpatient surgery. Thus, improvements in the quality and cost-efficiency of hospital-based care may require adjuncts to current ACO programs.

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 >4 U 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.

Many believe that variation in vascular practice may affect limb salvage rates in patients with severe peripheral arterial disease. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown.

Although the relationship between surgical volume and mortality is well established, the mechanisms underlying these associations remain uncertain. We sought to determine whether increased mortality at low-volume centers was due to higher complication rates or less success in rescuing patients from complications.

Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability. We sought to determine whether the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients.

Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer.

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 high-risk 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.Arch Surg. 2010;145(10):999-1004--

Individual quality measures have significant limitations for assessing surgical performance. Despite growing interest in composite measures, empirically-based methods for combining multiple domains of surgical quality are not well established.

Although racial disparities in the quality of surgical care are well described, the impact of socioeconomic status on operative mortality is relatively unexplored.

Except in cardiac surgery, measuring quality with procedure-specific mortality rates is unreliable because of small sample sizes at individual hospitals. Statistical power can be improved by combining mortality data from multiple operations. We sought to determine whether this approach would still be useful in understanding performance with individual procedures.

Although relations between procedure volume and operative mortality are well established for high‐risk cancer operations, differences in clinical practice between high‐volume and low‐volume centers are not well understood. The current study was conducted to examine relations between hospital volume, process of care, and operative mortality in cancer surgery. Using the Medicare claims database (2000‐2002), we identified all patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer (n= 71,558). Preoperative, intraoperative, and postoperative processes of care potentially related to operative mortality were identified from inpatient, outpatient, and physician claims files using appropriate International Classification of Diseases – Clinical Modification(ICD‐9) and Current Procedural Terminology (CPT) codes. We then assessed variation in the use of each process according to hospital volume, adjusting for patient characteristics and procedure type. Study Participants were US Medicare patients. The main outcome measure was specific processes of care. Relative to those at low‐volume centers (lowest 20th by volume), patients at high‐volume hospitals (highest 20th) were significantly more likely to undergo stress tests (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.21‐1.87), but not other preoperative imaging tests. They were more likely to see medical or radiation oncologists (OR: 1.37, 95% CI: 1.16‐1.62), but not other specialists, preoperatively. Although blood transfusions and use of epidural pain management did not vary significantly by volume, patients at high‐volume hospitals had significantly longer operations and were more likely to receive perioperative invasive monitoring (OR: 2.56, 95% CI: 1.82‐3.60). Differences in measurable processes of care did not explain volume‐related differences in operative mortality to any significant degree. Although high‐volume and low‐volume hospitals differ with regard to many aspects of perioperative care, mechanisms underlying volume–outcome relations in high‐risk cancer surgery remain to be identified. Cancer 2006. © 2006 American Cancer Society. While the relation between operative mortality and procedure volume is well established for high‐risk cancer operations, differences in clinical practice between high‐volume and low‐volume centers are not well understood. The authors identified all patients who underwent major resections for lung, esophageal, gastric, liver or pancreatic cancer using the 2000‐2002 Medicare claims database. They found that patients at high‐volume hospitals were more likely to undergo preoperative stress tests and see medical or radiation oncologists, operations were significantly longer and patients were more likely to receive perioperative invasive monitoring (OR 2.56, 95%CI 1.82‐3.60). Differences in measurable processes of care did not explain volume‐related differences in operative mortality to any significant degree.