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Background: Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants., Objectives: The purpose of this study was to determine whether outcomes improved over time within PC4., Methods: The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals., Results: During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay., Conclusions: This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Importance: As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions., Objective: To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions., Design, Setting, and Participants: This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period., Exposure: Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers., Main Outcomes and Measures: Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care., Results: A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period., Conclusions and Relevance: Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

Background: There is wide variation in mortality across hospitals for cancer operations. While higher rates of mortality are commonly ascribed to high-risk resections, the impact on more common operations is unclear. We sought to evaluate causes of mortality following colon cancer operations across hospitals., Methods: Forty-nine American College of Surgeons Commission on Cancer hospitals were selected for participation in a Commission on Cancer special study. We ranked hospitals using a composite measure of mortality and performed onsite chart reviews. We examined patient characteristics and mortality following colon resections at very high-mortality and very low- mortality hospitals (2006-2007)., Results: We identified 3,025 patients who underwent an operation at 19 low-mortality (n = 1,006) and 30 high-mortality (n = 2,019) hospitals. There were wide differences in risk-adjusted mortality between high-mortality and low-mortality hospitals (9.3% vs 2.4%; P < .001). Compared with low-mortality hospitals, high-mortality hospitals had more patients who were black (11.2% vs 6.5%; P < .001), had ≥2 comorbidities (22.7% vs 18.9%; P < .05), were categorized American Society of Anesthesiologists class 4-5 (11.9% vs 5.3%; P < .001), and were functionally dependent (13.9% vs 8.8%; P < .001). Rates of complication were similar in high-mortality versus low-mortality hospitals (odds ratio 1.29, 95% confidence interval, 0.85-1.95). For those experiencing complications, though, case fatality rates were significantly higher in high-mortality versus low-mortality hospitals (odds ratio 3.74, 95% confidence interval, 1.59-8.82)., Conclusion: There is significant variation in mortality across hospitals for colon cancer operations, despite similar perioperative morbidity. This finding reflects a need for improved operative decision-making to enhance outcomes and quality of care at these hospitals., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Evidence suggests that prolonged operative time adversely affects surgical outcomes. However, whether faster surgeons have better outcomes is unclear, as a surgeon׳s speed could reflect skill and efficiency, but may alternatively reflect haste. This study evaluates whether median surgeon operative time is associated with adverse surgical outcomes after laparoscopic Roux-en-Y gastric bypass., Methods: We performed a retrospective cohort study using statewide clinical registry data from the years 2006 to 2012. Surgeons were ranked by their median operative time and grouped into terciles. Multivariable logistic regression with robust standard errors was used to evaluate the influence of median surgeon operative time on 30-day surgical outcomes, adjusting for patient and surgeon characteristics, trainee involvement, concurrent procedures, and the complex interaction between these variables., Results: A total of 16,344 patients underwent surgery during the study period. Compared to surgeons in the fastest tercile, slow surgeons required 53 additional minutes to complete a gastric bypass procedure (median [interquartile range] 139 [133-150] versus 86 [69-91], P<.001). After adjustment for patient characteristic only, slow surgeons had significantly higher adjusted rates of any complication, prolonged length of stay, emergency department visits or readmissions, and venous thromboembolism (VTE). After further adjustment for surgeon characteristics, resident involvement, and the interaction between these variables, slow surgeons had higher rates of any complication (10.5% versus 7.1%, P=.039), prolonged length of stay (14.0% versus 4.4%, P=.002), and VTE (0.39% versus .22%, P<.001)., Conclusion: Median surgeon operative duration is independently associated with adjusted rates of certain adverse outcomes after laparoscopic Roux-en-Y gastric bypass. Improving surgeon efficiency while operating may reduce operative time and improve the safety of bariatric surgery., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to determine whether the changes in incentive design in phase 2 of Medicare's flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals., Background: The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown., Methods: We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates., Results: After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92-1.28] or joint replacement (OR = 0.81; 95% CI, 0.58-1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97-1.14) or joint replacement (OR = 1.12; 95% CI, 1.01-1.23). Analysis of the "worst" quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78-1.32) for CABG and (OR = 0.96; 95% CI, 0.22-4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88-1.34) for CABG and (OR = 0.92; 95% CI, 0.67-1.28) for joint replacement]., Conclusions: Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.

Background: Although resident involvement has been shown to be safe for most procedures, the impact of residents on outcomes after complex laparoscopic procedures is not well understood. We sought to examine the impact of resident involvement on outcomes after bariatric surgery using a population-based clinical registry., Study Design: We analyzed 17,057 patients who underwent a primary laparoscopic gastric bypass in the 35-hospital Michigan Bariatric Surgery Collaborative from July 2006 to August 2012. Resident involvement was characterized at the surgeon level. Using hierarchical logistic regression, we examined the influence of resident involvement on 30-day complications, accounting for patient characteristics as well as hospital and surgeon case volume. To evaluate potential mediating factors for specific complications, we also adjusted for operative duration., Results: Risk-adjusted 30-day complication rates with and without residents were 13.0% and 8.5%, respectively (p < 0.01). Resident involvement was independently associated with wound infection (odds ratio [OR] = 2.06; 95% CI, 1.24-3.43) and venous thromboembolism (OR = 2.01; 95% CI, 1.19-3.40), but not with any other medical or surgical complications. Operative duration was longer with resident involvement (median duration with residents 129 minutes vs 88 minutes without; p < 0.01). After adjusting for operative duration, resident involvement was still independently associated with wound infection (OR = 1.67; 95% CI, 1.01-2.76), but not venous thromboembolism (OR = 1.73; 95% CI, 0.99-3.04)., Conclusions: Resident involvement in laparoscopic gastric bypass is independently associated with wound infections and venous thromboembolism. The effect appears to be mediated in part by longer operative times. These findings highlight the importance of strategies to assess and improve resident technical proficiency outside the operating room., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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 119434 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: 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.

Background: Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes., Methods: We conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients., Results: Mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, as compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01). The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes, P<0.001) and higher rates of reoperation (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001)., Conclusions: The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency.

Importance: Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations., Objective: To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients., Design, Setting, and Patients: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy)., Main Outcome Measures: Risk-adjusted rates of any complication, serious complications, and reoperation., Results: Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17])., Conclusions and Relevance: Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

Purpose: 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., Methods: We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied., Results: We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001)., Conclusions: Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

Background: Failure to rescue (ie, mortality after a major complication) has recently been demonstrated as a mechanism underlying differences between high and low mortality hospitals. In this study, we sought to better understand the hospital characteristics that may explain failure to rescue., Study Design: Using data from the 2000 to 2006 Nationwide Inpatient Sample and the American Hospital Association annual survey, we evaluated the effect of 5 hospital level characteristics on failure to rescue (FTR) rates. Using multivariate logistic regression models, we determined the relative contribution of each of these factors to the FTR rates at the lowest and highest mortality hospitals., Results: Failure to rescue varied 6-fold across hospitals (6.4% in very low mortality hospitals vs 40.0% in very high mortality hospitals, p < 0.001). Several hospital characteristics were significantly associated with lower FTR: teaching status (odds ratio [OR] 0.66, 95% CI 0.53 to 0.82), hospital size greater than 200 beds (OR 0.65, 95% CI 0.48 to 0.87), average daily census greater than 50% capacity (OR 0.56, 95%CI 0.32 to 0.98), increased nurse-to-patient ratios (OR 0.94, 95% CI 0.89 to 0.99), and high hospital technology (OR 0.65, 95% CI 0.52 to 0.81). Including all hospital characteristics into a multivariate model results in a 36% reduction in the odds of FTR between very high and very low mortality hospitals (OR 6.6, 95% CI 3.7 to 11.9)., Conclusions: Several hospital characteristics are associated with FTR from major complications. However, a large portion of what makes some hospitals better than others at rescuing patients remains unexplained. Future research should focus on hospital cultures and attitudes that may contribute to the timely recognition and effective management of major complications., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To assess relationships between inferior vena cava (IVC) filter placement and complications within 30 days of gastric bypass surgery., Summary of Background Data: IVC filters are increasingly being used as prophylaxis against postoperative pulmonary embolism in patients undergoing bariatric surgery, despite a lack of evidence of effectiveness., Methods: On the basis of data from a prospective clinical registry involving 20 Michigan hospitals, we identified 6376 patients undergoing gastric bypass surgery between 2006 and 2008. We then assessed relationships between IVC filter placement and complications within 30 days of surgery. We used propensity scores and fixed effects logistic regression to control for potential selection bias., Results: A total of 542 gastric bypass patients (8.5%) underwent preoperative IVC filter placement, most of whom (65%) had no history of venous thromboembolism. The use of IVC filters for gastric bypass patients varied widely across hospitals (range, 0%-34%). IVC filter patients did not have reduced rates of postoperative venous thromboembolism (adjusted odds ratio [OR], = 1.28; 95% confidence interval [CI], 0.51-3.21), serious complications (adjusted OR, = 1.40; 95% CI, 0.91-2.16), or death/permanent disability (adjusted OR, = 2.49; 95% CI, 0.99-6.26). More than half (57%) of the IVC filter patients in the latter group had a fatal pulmonary embolism or complications directly related to the IVC filter itself, including filter migration or thrombosis of the vena cava. In subgroup analyses, we were unable to identify any patient group for whom IVC filters were associated with improved outcomes., Conclusions: Prophylactic IVC filters for gastric bypass surgery do not reduce the risk of pulmonary embolism and may lead to additional complications.

Context: Despite the growing popularity of bariatric surgery, there remain concerns about perioperative safety and variation in outcomes across hospitals., Objective: To assess complication rates of different bariatric procedures and variability in rates of serious complications across hospitals and according to procedure volume and center of excellence (COE) status., Design, Setting, and Patients: Involving 25 hospitals and 62 surgeons statewide, the Michigan Bariatric Surgery Collaborative (MBSC) administers an externally audited, prospective clinical registry. We evaluated short-term morbidity in 15,275 Michigan patients undergoing 1 of 3 common bariatric procedures between 2006 and 2009. We used multilevel regression models to assess variation in risk-adjusted complication rates across hospitals and the effects of procedure volume and COE designation (by the American College of Surgeons or American Society for Metabolic and Bariatric Surgery) status., Main Outcome Measure: Complications occurring within 30 days of surgery., Results: Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications. Serious complications were most common after gastric bypass (3.6%; 95% confidence interval [CI], 3.2%-4.0%), followed by sleeve gastrectomy (2.2%; 95% CI, 1.2%-3.2%), and laparoscopic adjustable gastric band (0.9%; 95% CI, 0.6%-1.1%) procedures (P < .001). Mortality occurred in 0.04% (95% CI, 0.001%-0.13%) of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% (95% CI, 0.08%-0.25%) of the gastric bypass patients. After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% (95% CI, 1.3-2.0) to 3.5% (95% CI, 2.4-5.0) (risk difference, 1.9; 95% CI, 0.08-3.7) across hospitals. Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (< 150 cases, 4.1%; 95% CI, 3.0%-5.1%; 150-299 cases, 2.7%; 95% CI, 2.2-3.2; and > or = 300 cases, 2.3%; 95% CI, 2.0%-2.6%; P = .003) and surgeon level (< 100 cases, 3.8%; 95% CI, 3.2%-4.5%; 100-249 cases, 2.4%; 95% CI, 2.1%-2.8%; > or = 250 cases, 1.9%; 95% CI, 1.4%-2.3%; P = .001). Adjusted rates of serious complications were similar in COE and non-COE hospitals (COE, 2.7%; 95% CI, 2.5%-3.1%; non-COE, 2.0%; 95% CI, 1.5%-2.4%; P = .41)., Conclusions: The frequency of serious complications among patients undergoing bariatric surgery in Michigan was relatively low. Rates of serious complications are inversely associated with hospital and surgeon procedure volume, but unrelated to COE accreditation by professional organizations.

Objective: We sought to determine whether hospital variations in surgical mortality were due to differences in complication rates or failure to rescue rates (ie, case-fatality rates in patients with a complication)., Background: Wide variations in mortality after major surgery are becoming increasingly apparent. The clinical mechanisms underling these variations are largely unexplored., Methods: We studied all Medicare beneficiaries undergoing 6 major operations in 2005 to 2006: pancreatectomy, esophagectomy, abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. We ranked hospitals according to risk-adjusted mortality and divided them into 5 equal groups. We then compared the incidence of complications and rates of failure to rescue between the top 20% of hospitals ("best") and bottom 20% of hospitals ("worst"). Analyses were conducted for all operations combined and for each individual procedure., Results: For all 6 operations combined, the worst hospitals had mortality rates 2.5-fold higher than the best hospitals (8.0% vs. 3.0%). However, complication rates were similar at worst and best hospitals (36.4% vs. 32.7%). In contrast, failure to rescue rates were much higher at the worst compared with the best hospitals (16.7% vs. 6.8%). These findings persisted in analyses with individual operations and specific complications., Conclusions: Reducing variations in mortality will require strategies to improve the ability of high-mortality hospitals to manage postoperative complications.

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., (2009 Massachusetts Medical Society)

A retrospective, single-center study was conducted to understand variation in mortality after elective cancer surgery. Fifty-two patients who died perioperatively after elective cancer resections (colon, esophageal, pancreatic, lung, gastric and liver) were identified. A methodology was developed and used during medical record review to capture the occurrence and chronology of 21 postoperative complications. Data were reviewed by 3 attending surgeons who assigned cause of death based on information from the entire clinical record. This methodology demonstrated good construct validity, with 81% agreement between cause of death assigned by expert review of data from the instrument and that assigned by expert review of the clinical records (kappa = 0.75, P < .005). Cause-specific mortality can be reliably and systematically measured after cancer surgery. Understanding variation in cause-specific mortality can inform future quality improvement efforts.