Search

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 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]

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.

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]

Background: Hospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important. Methods: We studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications. Results: Rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortality hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quintiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations. Conclusions: In addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur. N Engl J Med 2009;361:1368-75. [ABSTRACT FROM AUTHOR]

Surgical mortality varies widely across hospitals and surgeons, more than would be predicted by chance alone or differences in case mix. Although a large body of research has suggested the importance procedure volume, clinical mechanisms underlying variation in surgical mortality remain largely unknown. Payers, policy makers, and professional of organizations have implemented a variety of large-scale strategies aimed at improving outcomes. Selective referral, process compliance, and outcomes measurement reflect different philosophies on how best to improve surgical quality and have distinct advantages and disadvantage. The optimal strategy may depend on both the clinical context (e.g., which procedure) and political realities. [ABSTRACT FROM AUTHOR]

Background: It is a widely held belief that detailed risk-adjustment is always necessary in comparative reports of surgical performance. We sought to evaluate the importance of risk-adjustment for two cardiac surgery report cards in New York and Pennsylvania. Study Design: We abstracted data directly from publicly available cardiac surgery report cards from New York State (2001 and 2002) and Pennsylvania (2000 and 2002). We first estimated the correlation between unadjusted and risk-adjusted mortality rates. We then divided hospitals into three groups of historic performance (best, average, and worst) for both unadjusted and risk-adjusted mortality rankings. We then calculated the risk-adjusted mortality within each of these groups using data from the report card from the subsequent year. Results: Risk-adjusted and unadjusted mortality rates were highly correlated for both New York (Pearson''s r =0.95; Spearman''s r =0.91) and Pennsylvania (Pearson''s r =0.87; Spearman''s r =0.89). For both states, risk-adjusted and unadjusted rankings were equally good at predicting subsequent mortality. In New York State, mortality for hospitals in the worst group was 50% higher than that in the best group regardless of whether unadjusted (relative risk [RR], 1.51) or adjusted (RR, 1.49) rankings were used. The same was found in Pennsylvania, where the results for unadjusted (RR, 1.53) and adjusted (RR, 1.45) rankings were nearly identical. Conclusions: Based on data from two prominent state registries, risk-adjusted and unadjusted mortality rates provide nearly identical estimates of hospital performance with coronary artery bypass. Risk-adjustment may not always be important for identifying high quality hospitals. [Copyright &y& Elsevier]

The article focuses on a study which suggests that bladder cancer patients undergoing radical cystectomy at hospitals with high lymph node counts tend to have higher survival rates. It states that hospitals with low lymph node count tended to treat those who were older, had more comorbidity, were of lower socioeconomic status and had lower procedure volumes. It cites that lymph node counts may reflect changing practice patterns according to physician characteristics, such as specialized oncology training.

Background: Surgeons with advanced training have lower mortality rates with some surgical procedures. The objective of the current study was to investigate the impact of thoracic surgery training on mortality rates of esophageal cancer resection. Methods: We studied esophageal cancer resection in the national Medicare population during 1998 and 1999. Operative mortality rates (in-hospital or 30-day) were compared for thoracic surgeons and other surgeons, adjusting for patient characteristics, hospital volume, and surgeon volume. Surgeons with specialty training in thoracic surgery were those certified by the American Board of Thoracic Surgery. Results: Of the 1,946 patients, 625 (32%) had their operation performed by a thoracic surgeon. After adjustment for patient characteristics, mortality rates were 37% (odds ratio, 1.37; 95% confidence interval, 1.02 to 1.82) higher for surgeons without specialty training compared with thoracic surgeons (adjusted mortality 16.5% versus 12.4%; p = 0.01). However, differences in mortality between high-volume and low-volume hospitals (24.3% versus 11.4%; p &#60; 0.001) and surgeons (20.7% versus 10.7%; p &#60; 0.001) were larger than those between thoracic and general surgeons. Although thoracic surgeons had lower mortality rates after adjusting for hospital volume, the effect of thoracic surgery training was no longer significant after accounting for surgeon volume (odds ratio, 1.23; 95% confidence interval, 0.92 to 1.63). Conclusions: Specialty training in thoracic surgery has an independent association with lower mortality after esophageal resection. But specialty training appears to be less important than hospital and surgeon volume. [Copyright &y& Elsevier]

Context Surgical mortality rates are increasingly used to measure hospital quality. It is not clear, however, how many hospitals have sufficient caseloads to reliably identify quality problems. Objective To determine whether the 7 operations for which mortality has been advocated as a quality indicator by the Agency for Healthcare Research and Quality (coronary artery bypass graft [CABG] surgery, repair of abdominal aortic aneurysm, pancreatic resection, esophageal resection, pediatric heart surgery, craniotomy, hip replacement) are performed frequently enough to reliably identify hospitals with increased mortality rates. Design and Setting The US national average mortality rates and hospital caseloads of the 7 operations were determined using the 2000 Nationwide Inpatient Sample (NIS), and sample size calculations were performed to determine the minimum caseload necessary to reliably detect increased mortality rates in poorly performing hospitals. A 3-year hospital caseload was used for the baseline analysis, and poor performance was defined as a mortality rate double the national average. Main Outcome Measure Proportion of hospitals in the United States that performed more than the minimum caseload for each operation. Results The national average mortality rates for the 7 procedures examined ranged from 0.3% for hip replacement to 10.7% for craniotomy. Minimum hospital caseloads necessary to detect a doubling of the mortality rate were 64 cases for craniotomy, 77 for esophageal resection, 86 for pancreatic resection, 138 for pediatric heart surgery, 195 for repair of abdominal aortic aneurysm, 219 for CABG surgery, and 2668 for hip replacement. For only 1 operation did the majority of hospitals exceed the minimum caseload, with 90% of hospitals performing CABG surgery having a caseload of 219 or higher. For the remaining operations, only a small proportion of hospitals met the minimum caseload: craniotomy (33%), pediatric heart surgery (25%), repair of abdomina... [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]

A response by Amir A. Ghaferi, John D. Birkmeyer and Justin B. Dimick to a letter to the editor about their article "Variation in Hospital Mortality Associated With Inpatient Surgery" in the October 1, 2009 issue is presented.

Background: Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain. Methods: Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers. Results: Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure — from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced. Conclusions: For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently. N Engl J Med 2003;349:2117-27. [ABSTRACT FROM AUTHOR]

A response by John D. Birkmeyer and Emily V.A. Finlayson to several letters to the editor in response to their article "Hospital Volume and Surgical Mortality in the United States" in the April 11, 2002 issue is presented.

Background: Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case series from selected centers. Population-based data can provide more realistic estimates of the risks and benefits of operations in this group.Study Design: We performed a retrospective cohort study of patients undergoing major resections for lung, esophageal, and pancreas cancer. Using the Nationwide Inpatient Sample (1994 to 2003), we examined operative mortality and discharge disposition in octogenarians (aged 80+ years), relative to younger patients (aged 65 to 69 years) (n = 272,662). We then used the Surveillance and End Results-Medicare-linked database (1992 to 2001) to measure late survival in the elderly (n = 14,088).Results: Operative mortality among octogenarians was substantially higher than that of younger patients (aged 65 to 69 years) for all three cancers (esophagectomy, 19.9% versus 8.8%, p < 0.0001; pancreatectomy, 15.5% versus 6.7%, p < 0.0001; lung resection, 6.9% versus 3.7%, p < 0.0001). A large proportion of octogenarians were transferred to extended care facilities after operation, ranging from 24% after lung resection to 44% after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11% after pancreatectomy, 18% after esophagectomy and 31% after lung cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbid diagnoses--10% versus 14% for pancreatectomy, 15% versus 23% for esophagectomy, and 27% versus 37% for lung resection.Conclusions: Population-based outcomes after high-risk cancer operation in octogenarians are considerably worse than typically reported in case series and published survival statistics. Such information might better inform clinical decision making in this high-risk group. [ABSTRACT FROM AUTHOR]

Objectives: High-volume hospitals have lower mortality rates for a wide range of surgical procedures, including cystectomy for bladder cancer. However, the processes of care that mediate this effect are unknown. We sought to identify the processes that underlie the volume-outcome relationship for cystectomy.Methods: Within the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set, we used International Classification of Diseases (ICD)-9 procedure codes to identify 4465 patients who underwent cystectomy for bladder cancer between 1992 and 1999. The preoperative and perioperative processes of care were abstracted from the inpatient, outpatient, and physician files using the procedure and diagnosis codes available through 2002. Logistic models were used to assess the relationship between the process and hospital volume, adjusting for differences in patient characteristics.Results: Substantial variation was found in the use of specific processes of care across the hospital volume strata. High-volume hospitals had greater rates of preoperative cardiac testing (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.24 to 1.98), intraoperative arterial monitoring (OR 3.73, 95% CI 3.11 to 4.46), and the use of a continent diversion (OR 4.01, 95% CI 3.03 to 5.30), among many others. Patients treated at low-volume hospitals were 48% more likely to die in the postoperative period (4.9% versus 3.5%, adjusted OR 1.48, 95% CI 1.03 to 2.13). Differences in the use of processes of care explained 23% of this volume-mortality effect.Conclusions: High-volume and low-volume hospitals differ with regard to many processes of care before, during, and after radical cystectomy. Although these practices have partly explained the volume-outcome relationships for cystectomy, the primary mechanisms underlying this effect remain unclear. [ABSTRACT FROM AUTHOR]

Hospital executives pursue external recognition to improve market share and demonstrate institutional commitment to quality of care. The Magnet Recognition Program of the American Nurses Credentialing Center identifies hospitals that epitomize nursing excellence, but it is not clear that receiving Magnet recognition improves patient outcomes. Using Medicare data on patients hospitalized for coronary artery bypass graft surgery, colectomy, or lower extremity bypass in 1998-2010, we compared rates of risk-adjusted thirty-day mortality and failure to rescue (death after a postoperative complication) between Magnet and non-Magnet hospitals matched on hospital characteristics. Surgical patients treated in Magnet hospitals, compared to those treated in non-Magnet hospitals, were 7.7 percent less likely to die within thirty days and 8.6 percent less likely to die after a postoperative complication. Across the thirteen-year study period, patient outcomes were significantly better in Magnet hospitals than in non-Magnet hospitals. However, outcomes did not improve for hospitals after they received Magnet recognition, which suggests that the Magnet program recognizes existing excellence and does not lead to additional improvements in surgical outcomes. [ABSTRACT FROM AUTHOR]

Background Perioperative mortality in the elderly is high after emergency surgery and varies considerably among hospitals—an observation partially explained by differences in failure to rescue. We hypothesize that failure to rescue after certain types of complications underlies the disproportionately poor outcomes observed in elderly patients. Study Design We identified 23,217 patients undergoing emergent general or vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2007 and 2012. Patients' first complications were identified and categorized by type. We compared failure to rescue rates at the patient-level between patients younger than 75 and 75 years of age and older. We then compared failure to rescue rates after specific complications across hospitals grouped in tertiles by risk-adjusted 30-day mortality. Results Risk-adjusted failure to rescue rates were significantly higher in the elderly after a first infectious (21.7% vs 10.3%; p < 0.01) or pulmonary (38.2% vs 20.4%; p < 0.01) complication when compared with younger patients. At the hospital level, high-mortality centers failed to rescue elderly patients more frequently than low-mortality centers after a first infectious (35.6% vs 22.2%; p < 0.01) and pulmonary (24.3 vs 14.3; p < 0.01) complication. Failure to rescue rates after cardiovascular complications did not differ significantly across patient ages or tertiles of hospital mortality. Conclusions Hospitals fail to rescue elderly patients at higher rates than younger patients after infectious and pulmonary complications. Efforts to recognize and manage these specific complications have the potential to improve emergency surgical care of the elderly in Michigan. [ABSTRACT FROM AUTHOR]

The article discusses variation in the use of surgery. There are four categories in interventions aimed at the decision pathway to surgery, which includes the effect of evidence on the provision of surgery for specific disorders and the feedback on clinician performance versus peer performance or guidelines. One way to correct unwanted variation in surgical provision is to manipulate the number of specialists practicing in a specified medical area.

Background: The American College of Surgeons'' National Surgical Quality Improvement Program (ACS NSQIP) will soon be reporting procedure-specific outcomes, and hopes to reduce the burden of data collection by collecting fewer variables. We sought to determine whether these changes threaten the robustness of the risk adjustment of hospital quality comparisons. Study Design: We used prospective, clinical data from the ACS NSQIP from 2005 to 2007 (184 hospitals, 74,887 patients). For the 5 general surgery operations in the procedure-specific NSQIP, we compared the ability of the full model (21 variables), an intermediate model (12 variables), and a limited model (5 variables) to predict patient outcomes and to risk-adjust hospital outcomes. Results: The intermediate and limited models were comparable with the full model in all analyses. In the assessment of patient risk, the limited and full models had very similar discrimination at the patient level (C-indices for all 5 procedures combined of 0.93 versus 0.91 for mortality and 0.78 versus 0.76 for morbidity) and showed good calibration across strata of patient risk. In assessing hospital-specific outcomes, results from the limited and full-risk models were highly correlated for both mortality (range 0.94 to 0.99 across the 5 operations) and morbidity (range 0.96 to 0.99). Conclusions: Procedure-specific hospital quality measures can be adequately risk-adjusted with a limited number of variables. In the context of the ACS NSQIP, moving to a more limited model will dramatically reduce the burden of data collection for participating hospitals. [Copyright &y& Elsevier]

Although payers increasingly report information on hospital volume and mortality from surgery, the value of these data is uncertain. Using national Medicare data for six surgical operations (covering the years 2003-2006), we created a composite measure based on these two quality indicators. We found that this simple measure was a strong predictor of future performance for all six operations. In this regard, it was more effective than the individual measures. Such measures would be useful for helping patients and payers identify low-mortality hospitals for major surgery. [ABSTRACT FROM AUTHOR]

Background: African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear. Study design: Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality. Results: African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20). Conclusions: Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients. [Copyright &y& Elsevier]