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The study attempts to evaluate the rates of hospital complications associate with bariatric surgery across hospitals and according to procedure volume in Michigan. The results indicate that the frequency of serious complications in the case of such patients was relatively low, and that rates of complications were inversely associated with hospital and procedure value.

A study was conducted among Medicare beneficiaries to determine whether the opening of specialty cardiac hospitals was associated with greater population-based rates of coronary revascularization. Results revealed that opening a specialty cardiac hospital within a hospital referral region (HRR) was associated with increasing use of coronary revascularization among Medic are beneficiaries.

Surgical mortality rates are increasingly used to measure hospital quality however it is not clear how many hospitals have sufficient caseloads to reliably identify quality problems. The result show that except for coronary artery bypass graft (CABG) surgery, the operations for which surgical mortality is advocated as a quality indicator are not performed frequently enough to judge hospital quality.

Performing specific operations at specific hospitals would not substantially increase patients' travel times provided the hospital only has to do a small number of operations every year, according to a study of 15,796 Medicare patients. If so, more hospitals would qualify and most patients would not have to travel very far to reach a qualified hospital. Studies have shown that surgery patients have better outcomes if treated by surgeons who perform the operation frequently.

Mortality rates following carotid endarterectomy (CEA) may be much higher in routine practice than the rates seen in two clinical trials of CEA. The NASCET trial achieved a post-operative death rate of 0.6% and that in the ACAS trial was 0.1%. Researchers analyzed post-operative death rates in 113,300 Medicare patients who had CEA. Some had the procedure in the same hospitals that participated in the trials. The overall mortality rate was 1.4% in the trial hospitals and from 1.7% to 2.5% in non-trial hospitals, depending on how many CEAs the surgeons performed. Hospitals that performed fewer CEAs had higher mortality rates., Context.--The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS) demonstrated the efficacy of carotid endarterectomy (CEA) in reducing the risk of stroke and death in selected patents when surgery was performed in institutions whose participation depended on demonstrated excellence. Thirty-day mortality rates in the trials were very low: 0.6% in NASCET and 0.1% in ACAS. Objective.--To assess perioperative mortality among Medicare patients undergoing CEA in all nonfederal institutional settings. Design.--Retrospective national cohort study. Setting and Patients.--All 113 300 Medicare patients undergoing CEA during 1992 and 1993 in "trial hospitals" (those participating in NASCET and ACAS, n=86) and "nontrial hospitals" (all other nonfederal institutions performing CEAs, n=2613). Nontrial hospitals were stratified into terciles based on volume of CEAs performed. Main Outcome Measures.--Crude and adjusted perioperative (30 day) mortality rates. Results.--The perioperative mortality rate was 1.4% (95% confidence interval [CI], 1.2%-1.7%) at trial hospitals; mortality in nontrial hospitals was higher: 1.7% (95% CI, 1.6%-1.8%) (high volume); 1.9% (95% CI, 1.7%-2.1%) (average volume); 2.5% (95% CI, 2.0%-2.9%) (low volume); (P for trend, [is less than] .001). In multivariate modeling, patients undergoing their procedures at trial hospitals had a mortality risk reduction of 15% (95% CI, 0%-31%) compared with high-volume nontrial hospitals, 25% (95% CI, 7%-40%) compared with average-volume hospitals, and 43% (950/0 CI, 25%-56%) compared with low-volume hospitals (P for trend, [is less than] .001). Conclusion.--Medicare patients' perioperative mortality following CEA is substantially higher than that reported in the trials, even in those institutions that participated in the randomized studies. Caution is advised in translating the efficacy of carefully controlled studies of CEA to effectiveness in everyday practice. JAMA 1998;279:1278-1281

A continuous quality improvement program could reduce mortality rates from coronary artery bypass graft (CABG) surgery. Researchers affiliated with the Northern New England Cardiovascular Disease Study Group implemented a program to give cardiovascular surgeons regular feedback on patient outcomes, teach them the principles of continuous quality improvement and encourage them to visit other sites. Twenty-three cardiovascular surgeons at five medical centers in Maine, New Hampshire and Vermont participated. Mortality rates among the 15,095 patients undergoing CABG surgery dropped 24% in the 27-month period following the implementation of the program between July, 1990 and April 1991. The reductions occurred in every hospital except the one with the lowest mortality rates at the start of the study. Male and female patients alike benefitted from the program., Objective.--To determine whether an organized intervention including data feedback, training in continuous quality improvement techniques, and site visits to other medical centers could improve the hospital mortality rates associated with coronary artery bypass graft (CABG) surgery. Design.--Regional intervention study. Patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected on CABG patients in Northern New England between July 1, 1987, and July 31, 1993. Setting.--This study included all 23 cardiothoracic surgeons practicing in Maine, New Hampshire, and Vermont during the study period. Patients.--Data were collected on 15 095 consecutive patients undergoing isolated CABG procedures in Maine, New Hampshire, and Vermont during the study period. Interventions.--A three-component intervention aimed at reducing CABG mortality was fielded in 1990 and 1991. The interventions included feedback of outcome data, training in continuous quality improvement techniques, and site visits to other medical centers. Main Outcome Measure.--A comparison of the observed and expected hospital mortality rates during the postintervention period. Results.--During the postintervention period, we observed the outcomes for 6488 consecutive cases of CABG surgery. There were 74 fewer deaths than would have been expected. This 24%, reduction in the hospital mortality rate was statistically significant (P=.001). This reduction in mortality rate was relatively consistent across patient subgroups and was temporally associated with the interventions. Conclusion.--We conclude that a multi-institutional, regional model for the continuous improvement of surgical care is feasible and effective. This model may have applications in other settings. (JAMA. 1996;275:841-846)

The safety benefits of solvent-detergent-treated frozen plasma (SD FP) seem to be outweighed by the costs. SD FP is a technique that purifies multiple units of blood plasma with a SD mixture. This process eliminates envelope-covered viruses such as HIV and hepatitis. Researchers applied a decision analysis model to a large hypothetical group of plasma-transfused patients. The model approximated the predicted benefits and costs of SD FP. Results revealed that one unit of SD FP lengthened patients' lives by approximately 35 minutes. The cost incurred for each unit of SD FP was about $19.30. These cost-benefit estimates were applied to national plasma transfusion figures. For the 2.2 million plasma units that are transfused into U.S. patients each year, SD FP would save 147 years of life at a cost $42.5 million. The cost effectiveness of SD FP was estimated at $289,300 per year of life. SD FP creates an increased risk of transmitting a nonenveloped virus such as the hepatitis A virus., Objective. - To determine the public health and economic implications of solvent-detergent-treated frozen plasma (SD FP). While this processing technique nearly eliminates the risk of transmitting lipid-enveloped viruses (hepatitis B and C and human immunodeficiency virus), it has associated costs and, because it requires pooling many plasma units, may increase risks of nonenveloped virus transmission. Design. - A previously published Markov decision analysis model was modified to assess transfusion-related outcomes in hypothetical cohorts of plasma recipients. In-hospital mortality and other characteristics were determined in 61 patients receiving plasma transfusions at a medium-sized tertiary care center to provide data for the model. Other parameters were obtained from the medical literature. Main Outcome Measures. - Expected SD FP costs, benefits, and cost-effectiveness, assessed as cost per quality-adjusted life-year saved. Results. - Compared with untreated plasma, a unit of SD FP produces a net benefit of 35 minutes in quality-adjusted life expectancy at a cost of about $19. Extrapolated to the 2.2 million plasma units transfused annually in the United States, SD FP would save 147 quality-adjusted life-years at a cost of $42.5 million. The marginal cost-effectiveness, $289 300 per quality-adjusted life-year saved in the baseline analysis, was most sensitive to estimates of SD treatment cost and the clinical setting of plasma use. in sensitivity analysis, the net benefit of SD FP was negated by the existence of even a minute risk of nonenveloped virus infection. Conclusions. - From a public health perspective, the relatively high costs and small benefits of reducing enveloped virus infection risks with SD FP (and the additional risks of nonenveloped virus transmission) do not appear to justify widespread implementation of this new technology.

Many lives might be saved if people scheduled for certain types of elective surgery have the operation at a hospital with experience in that type of surgery. These hospitals are often called high-volume hospitals because they treat large numbers of patients who require that type of surgery. A study in California found that 500 deaths could have been prevented if patients having 10 specific types of surgery had the surgery at a high-volume hospital instead of a low-volume hospital. Most patients would not have to travel more than 25 miles to get to a high-volume hospital.

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]

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.

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]

Context: Several studies suggest improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer. The National Quality Forum and other organizations recently endorsed a 12-node minimum as a measure of hospital quality.Objective: To assess whether hospitals that examine more lymph nodes after resection for colon cancer have superior late survival rates.Design, Setting, and Patients: Retrospective cohort study, using the national Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1995-2005), of US patients undergoing colectomy for nonmetastatic colon cancer (n = 30 625). Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into 4 evenly sized groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.Main Outcome Measures: Hospitals' lymph node examination rates in association with cancer staging, use of adjuvant chemotherapy (indicated for patients with node-positive disease), and 5-year survival rate.Results: Hospitals with the highest proportions of patients with examination of 12 or more lymph nodes tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery (adjusted hazard ratio, highest vs lowest hospital quartile, 0.95; 95% confidence interval, 0.88-1.03). Although the 4 hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors and had very similar overall unadjusted rates of adjuvant chemotherapy (26% vs 25%, highest vs lowest hospital quartile).Conclusions: The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention. [ABSTRACT FROM AUTHOR]

Background: Although initiatives to regionalize cancer surgery are already under way, the relative importance of volume in cancer surgery is disputed. Hypothesis: We examined surgical mortality with 8 cancer resections in the US population to better quantify the influence of hospital volume. Methods: Using information from the all-payer Nationwide Inpatient Sample (1995-1997), we examined mortality with 8 cancer resections (N = 195 152). After dividing patients into 3 evenly sized volume groups based on hospital procedure volume (low, medium, and high), we used regression techniques to describe relationships between hospital volume and in-hospital mortality, adjusting for patient characteristics. Results: Trends toward lower operative risks at high-volume hospitals were observed for 7 of the 8 procedures. However, differences between low- and highhigh-volume hospitals were statistically significant for only 3 operations (esophagectomy, 15.0% vs 6.5%; pancreatic resection, 13.1% vs 2.5%; and pulmonary lobectomy, 10.1% vs 8.9%, respectively). Although they did not reach statistical significance, absolute differences in mortality between low- and high-volume hospitals were greater than 1% for the following 3 procedures: gastrectomy, 8.7% vs 6.9%; cystectomy, 3.6% vs 2.5%; and pneumonectomy, 10.6% vs 8.9%, respectively. Mortality reductions for nephrectomy and colectomy were small. In general, in terms of absolute differences in mortality, the effect of volume was greatest in elderly patients. Conclusions: Operative mortality decreases with increasing hospital volume for several cancer resections. However, volume may be most important in patients who are older and at higher risk. [ABSTRACT FROM AUTHOR]

Background: Although laparoscopic repair of ventral hernia has become increasingly popular, its outcomes relative to open repair have not been well characterized. For this reason, we performed a meta-analysis of studies comparing open and laparoscopic ventral (including incisional) hernia repair. Hypothesis: Laparoscopic ventral hernia repair results in better short-term outcomes than open ventral hernia repair. Data Sources: Structured MEDLINE search for published studies. One unpublished study was also identified. Study Selection: Studies were selected on the basis of study design (comparison of laparoscopic and open ventral hernia repair). The 3 main outcome measures were perioperative complications, operative time, and length of hospital stay. Of 83 potential studies identified by abstract review, 8 (10%) met the inclusion criteria. Data Extraction: Two reviewers assessed each article to determine eligibility for inclusion and, where appropriate, abstracted information on patient characteristics and main outcome measures. Data Synthesis: Across 8 studies, 390 patients underwent open repair and 322 underwent laparoscopic repair. Perioperative complications were less than half as likely to occur in patients undergoing laparoscopic repair (14% vs 27%; P = .03; odds ratio, 0.42; 95% confidence interval, 0.29-0.68). Average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P = .02). No statistically significant difference in operative times was noted between laparoscopic and open repair (99 vs 96 minutes; P = .38). Conclusions: Laparoscopic ventral hernia repair offers lower complication rates and shorter length of stay than open repair. However, randomized controlled trials and studies with long-term follow-up are needed to confirm these findings and to assess long-term rates of hernia recurrence. [ABSTRACT FROM AUTHOR]

Hypothesis: To test our hypothesis that unplanned return to the operating room (OR) is a useful quality indicator, we examined how often and for what reasons patients go back to the OR in a broad-based general surgery practice. Design and Setting: Prospective cohort study at a rural tertiary care center. Patients: Consecutive series of 3044 patients undergoing general surgery procedures in the OR between September 1, 1998, and March 31, 2000. Information about all postoperative adverse events occurring before discharge or within 30 days (whichever was longer) was collected prospectively. Unplanned return to the OR was defined as any secondary procedure required for a complication resulting directly or indirectly from the index operation. Main Outcome Measures: Unplanned return to the OR, mortality, and hospital charges. Results: Overall, 107 (3.5%) had an unplanned return to the OR. A relatively small number of inpatient procedures accounted for a disproportionate share of unplanned reoperations, including colon resection (18% of total reoperations), renal transplant (9%), gastric bypass (6%), and pancreatic resection (6%). As expected, hospital charges were markedly higher for patients with unplanned returns to the OR. Reoperation was also associated with higher mortality rates; statistically significant increases were noted for pancreatic resection (33% vs 3.7%; P = .04), esophagogastrectomy (100% vs 4.2%; P = .002), and laparoscopic Nissen fundoplication (50% vs 0%; P = .01). Overall, 91 reoperations (85%) were for complications occurring at the original surgical site, including those related to an anastomosis (n = 16), surgical wound (n = 21), infection (n = 16), bleeding (n = 12), and other (n = 26). Conclusions: Unplanned returns to the OR occur across a broad spectrum of general surgical procedures and carry significant implications. Because they most often reflect problems related to the procedure itself, reoperation rates may be useful for monitor... [ABSTRACT FROM AUTHOR]

Hypothesis: There is regional variation in the use of laparoscopic cholecystectomy (LC) for acute cholecystitis in the New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) Medicare population. Design: Population-based, cross-sectional study. Setting: Hospital service areas (HSAs), small geographic areas reflecting local hospital markets, in New England. Patients: We identified from the claims database 21 570 Medicare patients undergoing cholecystectomy between 1995 and 1997. Patients with acute calculous cholecystitis but no bile duct stones (n=6156) were then identified using International Classification of Diseases, Ninth Revision diagnostic codes. To reduce variation by chance, we excluded patients residing in HSAs with fewer than 26 cases, leaving 5014 patients in 77 HSAs. Main Outcome Measures: For each HSA, we assessed the rate of cholecystectomies performed laparoscopically, mortality, and hospital length of stay. Results: Overall, 53.5% of patients with acute cholecystitis underwent LC. There was wide regional variation in the rate of patients undergoing laparoscopic surgery, from 30.3% in the Salem, Mass, HSA to 75.5% in the Hyannis, Mass, HSA. Seventeen HSAs had rates below 40%, while 9 had rates above 70%. The average length of stay (7.6 days) was approximately 1 day shorter in HSAs with high rates of patients undergoing LC than in other HSAs. There was no correlation between regional use of laparoscopic surgery and 30-day mortality (3.1% overall). Conclusions: The likelihood of elderly patients with acute cholecystitis receiving LC depends strongly on where they live. Efforts to reduce regional variation should focus on disseminating techniques for safe LC in this high-risk population. [ABSTRACT FROM AUTHOR]

Objective: To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG). Design: Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively. Setting: All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont. Patients: A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995. Main Outcome Measures: Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay. Results: A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P<.001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P< .001). High rates of reexploration for hemorrhage were observed in patients with prolonged (>150 minutes) cardiopulmonary bypass (39 [11.1] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus. Conclusions: Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage. [ABSTRACT FROM AUTHOR]

Presents a research letter to the editor which discusses trends in bariatric surgery in the United States. Illustrated data shows hospital characteristics and volume of surgery. Research methods used in this study are mentioned, including the analysis of data from the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample.

This article presents a letter to the editor regarding the article "Use of Breast Reconstruction After Mastectomy Following the Women's Health and Cancer Rights Act," published in a previous issue.

A letter to the editor is presented in response to the viewpoint by Doctors Steven and Katz and Sarah Hawley on patient-physician shared decision making.