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Weight loss after bariatric surgery can be accurately predicted using an outcomes calculator; however, outliers exist that do not meet the 1 year post-surgery weight projections.Our goal was to determine how soon after surgery these outliers can be identified.We conducted a retrospective cohort study.Using a bariatric surgery outcomes calculator formulated by the Michigan Bariatric Surgery Collaborative (MBSC), predicted weight loss at 1 year post-surgery was calculated on all patients who underwent primary bariatric surgery at a single-center academic institution between 2006 and 2015 who also had a documented 1-year follow-up weight (n = 1050).Weight loss curves were compared between high, low, and non-outliers as defined by their observed-to-expected (O:E) weight loss ratio based on total body weight loss (TBWL) %.Mean predicted weight loss for the study group was 39.1 ± 9.9 kg, while mean actual weight loss was 39.7 ± 17.1 kg resulting in a mean O:E 1.01 (± 0.35). Based on analysis of the O:E ratios at 1 year post-surgery, the study group was sub-classified. Low outliers (n = 188, O:E 0.51) had significantly lower weight loss at 2 months (13.1% vs 15.6% and 16.5% TBWL, p 0. 001) and at 6 months (19% vs 26% and 30% TBWL, p 0.001) when compared to non-outliers (n = 638, O:E 1.00) and high outliers (n = 224, O:E 1.46), respectively.Weight loss curves based on individually calculated outcomes can help identify low outliers for additional interventions as early as 2 months after bariatric surgery.

Meaningful reporting of quality metrics relies on detecting a statistical difference when a true difference in performance exists. Larger cohorts and longer time frames can produce higher rates of statistical differences. However, older data are less relevant when attempting to enact change in the clinical setting. The selection of time frames must reflect a balance between being too small (type II errors) and too long (stale data). We explored the use of power analysis to optimize time frame selection for trauma quality reporting.Using data from 22 Level III trauma centers, we tested for differences in 4 outcomes within 4 cohorts of patients. With bootstrapping, we calculated the power for rejecting the null hypothesis that no difference exists amongst the centers for different time frames. From the entire sample for each site, we simulated randomly generated datasets. Each simulated dataset was tested for whether a difference was observed from the average. Power was calculated as the percentage of simulated datasets where a difference was observed. This process was repeated for each outcome.The power calculations for the 4 cohorts revealed that the optimal time frame for Level III trauma centers to assess whether a single site's outcomes are different from the overall average was 2 years based on an 80% cutoff.Power analysis with simulated datasets allows testing of different time frames to assess outcome differences. This type of analysis allows selection of an optimal time frame for benchmarking of Level III trauma center data.

Failure to rescue (FTR) is defined as mortality following a complication. Failure to rescue has come under scrutiny as a quality metric to compare trauma centers. In contrast to elective surgery, trauma has an early period of high expected mortality because of injury sequelae rather than a complication. Here, we report FTR in early and late mortality using an externally validated trauma patient database, hypothesizing that centers with higher risk-adjusted mortality rates have higher risk-adjusted FTR rates.The study included 114,220 patients at 34 Levels I and II trauma centers in a statewide quality collaborative (2016-2020) with Injury Severity Score of ≥5. Emergency department deaths were excluded. Multivariate regression models were used to produce center-level adjusted rates for mortality and major complications. Centers were ranked on adjusted mortality rate and divided into quintiles. Early deaths (within 48 hours of presentation) and late deaths (after 48 hours) were analyzed.Overall, 6.7% of patients had a major complication and 3.1% died. There was no difference in the mean risk-adjusted complication rate among the centers. Failure to rescue was significantly different across the quintiles (13.8% at the very low-mortality centers vs. 23.4% at the very-high-mortality centers, p0.001). For early deaths, there was no difference in FTR rates among the highest and lowest mortality quintiles. For late deaths, there was a twofold increase in the FTR rate between the lowest and highest mortality centers (9.7% vs. 19.3%, p0.001), despite no difference in the rates of major complications (5.9% vs. 6.0%, p = 0.42).Low-performing trauma centers have higher mortality rates and lower rates of rescue following major complications. These differences are most evident in patients who survive the first 48 hours after injury. A better understanding of the complications and their role in mortality after 48 hours is an area of interest for quality improvement efforts.Prognostic and Epidemiologic; Level III.

Prospective payment models have incentivized reductions in length of stay after surgery. The benefits of abbreviated postoperative hospitalization could be undermined by increased readmissions or postacute care use, particularly for older adults or those with comorbid conditions.The purpose of this study was to determine whether hospitals with accelerated postsurgical discharge accrue total episode savings or incur greater postdischarge payments among patients stratified by age and comorbidity.This was a retrospective cross-sectional study.National data from the 100% Medicare Provider Analysis and Review files for July 2012 to June 2015 were used.We included Medicare beneficiaries undergoing elective colectomy and stratified the cohort by age (65-69, 70-79, ≥80 y) and Elixhauser comorbidity score (low: ≤0; medium: 1-5; and high:5). Patients were categorized by the hospital's mode length of stay, reflecting "usual" care.In a multilevel model, we compared mean total episode payments and components thereof among age and comorbidity categories, stratified by hospital mode length of stay.Among 88,860 patients, mean total episode payments were lower in shortest versus longest length of stay hospitals across all age and comorbidity strata and were similar between age groups (65-69 y: $28,951 vs $30,566, p = 0.014; 70-79 y: $31,157 vs $32,044, p = 0.073; ≥80 y: $33,779 vs $35,771, p = 0.005) but greater among higher comorbidity (low: $23,107 vs $24,894, p = 0.001; medium: $30,809 vs $32,282, p = 0.038; high: $44,097 vs $46641, p0.001). Postdischarge payments were similar among length-of-stay hospitals by age (65-69 y: ∆$529; 70-79 y: ∆$291; ≥80 y: ∆$872, p = 0.25) but greater among high comorbidity (low: ∆$477; medium: ∆$480; high: ∆$1059; p = 0.02).Administrative data do not capture patient-level factors that influence postacute care use (preference, caregiver availability).Hospitals achieving shortest length of stay after surgery accrue lower total episode payments without a compensatory increase in postacute care spending, even among patients at oldest age and with greatest comorbidity. See Video Abstract at http://links.lww.com/DCR/B624.ANTECEDENTES:Los modelos de pago prospectivo, han sido un incentivo para reducir la estancia hospitalaria después de la cirugía. Los beneficios de una hospitalización posoperatoria "abreviada" podrían verse afectados por un aumento en los reingresos o en la necesidad de cuidados postoperatorios tempranos luego del periodo agudo, particularmente en los adultos mayores o en aquellos con comorbilidades.OBJETIVO:Determinar si los hospitales que han establecido protocolos de alta posoperatoria "acelerada" generan un ahorro en cada episodio de atención o incurren en mayores gastos después del alta, entre los pacientes estratificados por edad y por comorbilidades.DISEÑO:Estudio transversal retrospectivo.AJUSTE:Revisión a partir de la base de datos nacional del 100% de los archivos del Medicare Provider Analysis and Review desde julio de 2012 hasta junio de 2015.PACIENTES:Se incluye a los beneficiarios de Medicare a quienes se les practicó una colectomía electiva. La cohorte se estratificó por edad (65-69 años, 70-79, ≥80) y por la puntuación de comorbilidad de Elixhauser (baja: ≤0; media: 1-5; y alta:5). Los pacientes se categorizaron de acuerdo con la modalidad de la duración de la estancia hospitalaria del hospital, lo que representa lo que se considera es una atención usual para dicho centro.PRINCIPALES MEDIDAS DE RESULTADO:En un modelo multinivel, comparamos la media de los pagos por episodio y los componentes de los mismos, entre las categorías de edad y comorbilidad, estratificados por la modalidad de la duración de la estancia hospitalaria.RESULTADOS:En los 88,860 pacientes, los pagos promedio por episodio fueron menores en los hospitales con una modalidad de estancia más corta frente a los de mayor duración, en todos los estratos de edad y comorbilidad, y fueron similares entre los grupos de edad (65-69: $28,951 vs $30,566, p = 0,014; 70-79: $31,157 vs $32,044, p = 0,073; ≥ 80 $33,779 vs $35,771, p = 0,005), pero mayor entre los pacientes con comorbilidades más altas (baja: $23,107 vs $24,894, p = 0,001; media $30,809 vs $32,282, p = 0,038; alta: $44,097 vs $46,641, p0,001). Los pagos generados luego del alta hospitalaria fueron similares con relación a la estancia hospitalaria de los diferentes hospitales con respecto a la edad (65-69 años: ∆ $529; 70-79 años: ∆ $291; ≥80 años: ∆ $872, p = 0,25), pero mayores en aquellos con más alta comorbilidad (baja ∆ $477, medio ∆ $480, alto ∆ $1059, p = 0,02).LIMITACIONES:Las bases de datos administrativas no capturan los factores del paciente que influyen en el cuidado luego del estado posoperatorio agudo (preferencia, disponibilidad del proveedor del cuidado).CONCLUSIONES:Los hospitales que logran una estancia hospitalaria más corta después de la cirugía, acumulan pagos más bajos por episodio, sin un incremento compensatorio del gasto en la atención pos-aguda, incluso entre pacientes de mayor edad y con mayor comorbilidad. Consulte Video Resumen en http://links.lww.com/DCR/B624. (Traducción-Dr Eduardo Londoño-Schimmer).

An individualized treatment rule (ITR) formalizes personalized medicine by assigning treatment as a function of patients' clinical information, which contrasts with a static treatment rule that assigns everyone the same treatment. ITR identification has become a common aim in randomized clinical trials but sample size considerations for this aim are lacking. One approach is to select a sample size that will reliably identify an ITR with a performance close to the theoretical optimal rule. However, this approach could still lead to identifying ITRs that perform worse than the optimal static rule, particularly in the absence of substantial effect heterogeneity. This limitation motivates sample size considerations aimed at reliable identification of a beneficial ITR, which outperforms the optimal static rule, and analysis methods that identify the estimated optimal static rule when there is substantial uncertainty about whether an ITR will improve outcomes. To address these limitations, we propose a sample size approach based on the probability of identifying a beneficial ITR and introduce an approach for selecting the LASSO penalty parameter such that in the absence of treatment effect heterogeneity the estimated optimal static rule is identified with high probability. We apply these approaches to the PLUTO trial aimed at developing methods to assist with smoking cessation.

BACKGROUND Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications. METHODS Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma-verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization

BACKGROUND Warfarin has been the oral anticoagulant of choice for the treatment of thromboembolic disease. However, upward of 50% of all new anticoagulant prescriptions are now for direct oral anticoagulants (DOAC). Despite this, outcome data evaluating preinjury anticoagulants remain scarce following traumatic brain injury (TBI). Our study objective is to determine the effects of preinjury anticoagulation on outcomes in older adults with TBI. METHODS Patient data were obtained from 29 level 1 and 2 trauma centers from 2012 to June 30, 2018. Overall, 8312 patients who were aged 65 years or older, suffering a ground level fall, and with an Abbreviated Injury Scale (AIS) head score of ≥ 3 were identified. Patients were excluded if they presented with no signs of life or a traumatic mechanism besides ground level fall. Statistical comparisons were made using multivariable analyses with anticoagulant/antiplatelet use as the independent variable. RESULTS Of the total patients with TBI, 3293 were on antiplatelet agents (AP), 669 on warfarin, 414 on warfarin + AP, 188 on DOACs, 116 on DOAC + AP, and 3632 on no anticoagulant. There were 185 (27.7%) patients on warfarin and 43 (22.9%) on a DOAC with a combined outcome of mortality or hospice as compared to 575 (15.8%) in the no anticoagulant group (p

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data. We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records. There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively). Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

BACKGROUND Accurate and reliable data are pivotal to credible risk-adjusted modeling and hospital benchmarking. Evidence assessing the reliability and accuracy of data elements considered as variables in risk-adjustment modeling and measurement of outcomes is lacking. This deficiency holds the potential to compromise benchmarking integrity. We detail the findings of a longitudinal program to evaluate the impact of external data validation on data validity and reliability for variables utilized in benchmarking of trauma centers. METHODS A collaborative quality initiative-based study was conducted of 29 trauma centers from March 2010 through December 2018. Case selection criteria were applied to identify high-yield cases that were likely to challenge data abstractors. There were 127,238 total variables validated (i.e., reabstracted, compared, and reported to trauma centers). Study endpoints included data accuracy (agreement between registry data and contemporaneous documentation) and reliability (consistency of accuracy within and between hospitals). Data accuracy was assessed by mean error rate and type (under capture, inaccurate capture, or over capture). Cohen's kappa estimates were calculated to evaluate reliability. RESULTS There were 185,120 patients that met the collaborative inclusion criteria. There were 1,243 submissions reabstracted. The initial validation visit demonstrated the highest mean error rate at 6.2% ± 4.7%, and subsequent validation visits demonstrated a statistically significant decrease in error rate compared with the first visit (p < 0.05). The mean hospital error rate within the collaborative steadily improved over time (2010, 8.0%; 2018, 3.2%) compared with the first year (p < 0.05). Reliability of substantial or higher (kappa ≥0.61) was demonstrated in 90% of the 20 comorbid conditions considered in the benchmark risk-adjustment modeling, 39% of these variables exhibited a statistically significant (p < 0.05) interval decrease in error rate from the initial visit. CONCLUSION Implementation of an external data validation program is correlated with increased data accuracy and reliability. Improved data reliability both within and between trauma centers improved risk-adjustment model validity and quality improvement program feedback.

Additional file 1.

Data accuracy is essential to obtaining correct results and making appropriate conclusions in outcomes research. Few have examined the quality of data that is used in studies involving orthopedic surgery. A nonspecific data entry has the potential to affect the results of a study or the ability to appropriately risk adjust for treatments and outcomes. This study evaluated the proportion of Not Further Specified (NFS) orthopedic injury codes found into two large trauma registries.Data from the National Trauma Data Bank (NTDB) from 2011 to 2015 and from the Michigan Trauma Quality Improvement Program (MTQIP) 2011-2017 were used. We selected multiple orthopedic injuries classified via the Abbreviated Injury Scale, version 2005 (AIS2005) and calculated the percentage of NFS entries for each specific injury.There were a substantial proportion of fractures classified as NFS in each registry, 18.5% (range 2.4%-67.9%) in MTQIP and 27% (range 6.0%-68.5%) in the NTDB. There were significantly more NFS entries when the fractures were complex versus simple in both MTQIP (34.5% versus 9.6%, P 0.001) and the NTDB (41.8% versus 15.7%, P 0.001). The level of trauma center affected the proportion of NFS codes differently between the registries.The proportion of nonspecific entries in these two large trauma registries is concerning. These data can affect the results and conclusions from research studies as well as impact our ability to truly risk adjust for treatments and outcomes. Further studies should explore the reasons for these findings.

Traumatic brain injury (TBI) is a leading cause of trauma-related death and disability. Computed tomography (CT) imaging of the head is essential for diagnosis of intracranial hemorrhage. This study aimed to identify optimal time to imaging and its impact on mortality for older patients with mild TBIs.State-wide quality collaborative data were used from level I-II trauma centers. Inclusion criteria were ICD-9/10 codes for head trauma, age ≥50, admission/emergency department Glasgow Coma Scale ≥14, injury severity score ≤20, nonfull trauma activation, and head CT imaging time between 5 and 90 min of arrival. Locally weighted scatterplot smoothing plot data were used to dichotomize patients into early and late head CT imaging cohorts. Multivariable logistic regression and negative binomial models were used to evaluate the effect of early verses late head CT on clinical outcomes. The primary outcome was in-hospital mortality.Mortality nadired at 35 min. Each 1-min delay in CT imaging resulted in a 2% increase in mortality (P = 0.002). Early patients had significantly reduced in-hospital mortality (P = 0.03), shorter emergency department length of stay (P 0.001), and were more likely to receive fresh frozen plasma within 4 h if anticoagulated (P = 0.03). Teaching, high-volume, and level 2 trauma centers were all less likely to provide early head CTs (all P 0.05).Delay in head CT imaging in the setting of potential mild TBI was associated with an increase in mortality. A delay in diagnosis cascades into delays in delivery of therapeutic interventions. Head CT within 35 min should be evaluated as a quality metric for older patients with mild TBI.

Postacute care costs are the primary determinant of episode spending around hospitalization. Yet there is little evidence that greater spending on postacute care improves readmission rates or functional recovery. Recent Medicare payment reform evaluations have suggested that postacute care spending is responsive to episode-based incentives. However, it remains unknown whether Medicare payment policies are responsible for excess postacute care spending, compared with that of commercial payers. In a population-based, statewide collaborative of Michigan hospitals, we used regression discontinuity design among propensity-weighted, age-adjusted cohorts to compare postacute care spending between patients with commercial insurance and those with Medicare around age sixty-five. Spending was 68–230 percent greater among fee-for-service Medicare beneficiaries than among similar commercially insured people across varied medical and surgical conditions. Despite greater spending, there were no differences in readmission rates. These findings suggest that postacute care utilization is highly sensitive to payer influence, and there may be an opportunity for additional savings in Medicare without sacrificing quality.

OBJECTIVE To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. SUMMARY BACKGROUND DATA Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. METHODS Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. RESULTS In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. CONCLUSIONS ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.

OBJECTIVE The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking. METHODS Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison. RESULTS A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied. CONCLUSION Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes. LEVEL OF EVIDENCE Prospective/Epidemiologic, Level III.

BACKGROUND: Venous thromboembolism (VTE) is a common complication in trauma patients. Pharmacologic prophylaxis is utilized in trauma patients to reduce their risk of a VTE event. The Eastern Association for the Surgery of Trauma guidelines recommend use of low-molecular-weight heparin (LMWH) as the preferred agent in these patients. However, there is literature suggesting that unfractionated heparin (UFH) is an acceptable, and less costly, alternative VTE prophylaxis agent with equivalent efficacy in trauma patients. We examined data from the Michigan Trauma Quality Improvement Program to perform a comparative effectiveness study of UFH versus LMWH on outcomes for trauma patients. METHODS: We conducted an analysis of the Michigan Trauma Quality Improvement Program data from January 2012 to December 2014. The data set contains information on date, time, and drug type of the first dose of VTE prophylaxis. Thirty-seven thousand eight hundred sixty-eight patients from 23 hospitals were present with an Injury Severity Score of 5 or greater and hospitalization for more than 24 hours. Patients were excluded if they died within 24 hours or received no pharmacologic VTE prophylaxis or agents other than UFH or LMWH while admitted to the hospital. We compared patients receiving LMWH to those receiving UFH. Outcomes assessed were VTE event, pulmonary embolism, deep vein thrombosis, and mortality during hospitalization. We used a generalized estimating equation approach to fit population-averaged logistic regression models with the type of first dose of VTE prophylaxis as the independent variable. Unfractionated heparin was considered the reference value. Timing of the first dose of VTE prophylaxis was entered into the model in addition to standard covariates. Odds ratios were generated for each of the dependent variables of interest. RESULTS: The analysis cohort consisted of 18,010 patients. Patients administered LMWH had a decreased risk of mortality (odds ratio, 0.64; confidence interval, 0.49–0.83), VTE (odds ratio, 0.67; confidence interval, 0.53–0.84), pulmonary embolism (odds ratio, 0.53; confidence interval, 0.35–0.79), and deep vein thrombosis (odds ratio, 0.73; confidence interval, 0.57–0.95) when compared with UFH following risk adjustment and accounting for hospital effect. The reduced risk of a VTE event for patients receiving LMWH was most pronounced for patients in the lower injury-severity categories. CONCLUSIONS: In our examination of VTE prophylaxis drug effectiveness, LMWH was found to be superior to UFH in reducing the incidence of mortality and VTE events among trauma patients. Therefore, LMWH should be the preferred VTE prophylaxis agent for use in hospitalized trauma patients. LEVEL OF EVIDENCE: Therapeutic, level III.

American College of Surgeons verified trauma centers and a third-party payer within the state of Michigan built a regional collaborative quality initiative (CQI). The Michigan Trauma Quality Improvement Program began as a pilot in 2008 and expanded to a formal program in 2011. Here, we examine the performance of the collaborative over time with regard to patient outcomes, resource utilization, and process measures.Data from the initial 23 hospitals that joined the CQI in 2011 were analyzed. Performance trends from 2011 to 2015 were evaluated for outcomes, resource utilization, and process measures using univariate analysis. Risk-adjustment was performed to confirm results observed in the unadjusted data. To calculate the potential number of patients impacted by the CQI program, the maximum absolute change was multiplied by the number of trauma patients treated in the 23 hospitals during 2015.Membership in a CQI program significantly reduced serious complications (8.5 vs. 7.3%, p = 0.002), decreased resource utilization, and improved process measure execution in trauma patients over 5 years time. Similar results were obtained in unadjusted and risk-adjusted analyses. The CQI program potentially avoided inferior vena cava filter placement in 167 patients annually. Decreased venous thromboembolism rates mirrored increased compliance with venous thromboembolism pharmacologic prophylaxis.This study confirms our hypothesis that participation in a regional CQI improves patient outcomes and decreases resource utilization while promoting compliance with processes of care.Economic/therapeutic care, level V.

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spendi...

Diabetes is associated with poor outcomes in critically ill populations. The goal of this study was to determine if diabetic patients suffer poorer outcomes following trauma. Collaborative trauma patient data from 2012-2018 was analyzed. Patients with no signs-of-life, Injury Severity Score (ISS)

This study uses Medicare Parts A and B claims data to compare hospitalizations for and spending on traumatic injury vs heart failure, pneumonia, stroke, and acute myocardial infarction in older adults between 2008 and 2014.

Background The population of patients on anticoagulant or antiplatelet therapy for medical conditions is increasing. The objective of this study was to investigate the effects of preinjury anticoagulation or antiplatelet therapy on outcomes after trauma. Methods This cohort study analyzed data from the Michigan Trauma Quality Improvement Program from 2012 to 2017 and included trauma patients age ≥16 years with an Injury Severity Score ≥5 treated at 29 hospitals. The primary outcome was in-hospital mortality. Results Of 115,042 trauma patients, 44.2% were women and 78.2% were white with a mean age (standard deviation) of 59.1 (23.2) years. A total of 23,196 patients were on antiplatelet therapy, 3,855 on warfarin, 1,893 on warfarin + antiplatelet agent, 1,306 on a direct oral anticoagulant, and 717 patients on direct oral anticoagulant + antiplatelet therapy. We observed an increased risk of mortality in patients on preinjury antiplatelet (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.02–1.33), warfarin (OR 1.32; 95% CI 1.05–1.65), or warfarin + antiplatelet therapy (OR 1.59; 95% CI 1.18–2.14). Patients on a direct oral anticoagulant only were not at statistically increased risk for mortality. Conclusion Preinjury antiplatelet and/or warfarin use was associated with an increased risk of mortality after traumatic injury. Preinjury direct oral anticoagulant use was not associated with a statistically increased risk of adverse outcomes.

BACKGROUND: Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques.METHODS: In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281.FINDINGS: Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (INTERPRETATION: Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction.FUNDING: National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Growth of an aging US population, coupled with implementation of the Patient Protection and Affordable Care Act, will pose logistical challenges for the primary care provider (PCP) workforce for the foreseeable future. In particular, the burden of otolaryngologic care placed on PCPs is substantial, based on research dating back to the 1970s and confirmed by a recent analysis of the US National Ambulatory Medical Care Survey. Collaboration between the otolaryngology and primary care communities will be needed to ensure that PCPs gain adequate exposure and training in routine otolaryngology care to improve the clinical management of ear, nose, and throat conditions in an expanding population.

Importance The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) provides feedback to hospitals on risk-adjusted outcomes. The Michigan Trauma Quality Improvement Program (MTQIP) goes beyond the provision of feedback alone, focusing on collaborative quality improvement. It is unknown whether the addition of a collaborative approach to benchmark reporting improves outcomes. Objective To evaluate the association of hospital participation in the ACS TQIP (benchmark reporting) or the MTQIP (benchmark reporting and collaborative quality improvement) with outcomes compared with control hospitals that did not participate in either program. Design, Setting, and Participants In this cohort study, data from the National Trauma Data Bank from 2009 to 2015 were used. A total of 2 373 130 trauma patients 16 years or older with an Injury Severity Score of 5 or more were identified from 98 ACS TQIP hospitals, 23 MTQIP hospitals, and 429 nonparticipating hospitals, based on program participation status in 2011. A difference-in-differences analytic approach was used to evaluate whether hospital participation in the ACS TQIP or the MTQIP was associated with improved outcomes compared with nonparticipation in a quality improvement program. Exposures Hospital participation in MTQIP, a quality improvement collaborative, compared with ACS TQIP participation and nonparticipating hospitals. Main Outcomes and Measures In-hospital mortality, mortality or hospice, major complications, and venous thromboembolism events were assessed. Results Of the 2 373 130 included trauma patients, 64.2% were men and 73.0% were white, and the mean (SD) age was 50.7 (21.9) years. After accounting for patient factors and preexisting time trends toward improved outcomes, there was a statistically significant improvement in major complications after (vs before) hospital enrollment in the MTQIP collaborative compared with nonparticipating hospitals (odds ratio [OR], 0.89; 95% CI, 0.83-0.95) or ACS TQIP hospitals (OR, 0.88; 95% CI, 0.82-0.94). A similar result was observed for venous thromboembolism (MTQIP vs nonparticipating: OR, 0.78; 95% CI, 0.69-0.88; MTQIP vs ACS TQIP: OR, 0.84; 95% CI, 0.74-0.95), for which MTQIP targeted specific performance improvement efforts. Hospital participation in both ACS TQIP and MTQIP was associated with improvement in mortality or hospice (ACS TQIP vs nonparticipating: OR, 0.90; 95% CI, 0.87-0.93; MTQIP vs nonparticipating: OR, 0.88; 95% CI, 0.81-0.96). Hospitals participating in MTQIP achieved the lowest overall risk-adjusted mortality in the postenrollment period (4.2%; 95% CI, 4.1-4.3). Conclusions and Relevance This study demonstrates that hospital participation in a regional collaborative quality improvement program is associated with improved patient outcomes beyond benchmark reporting alone while promoting compliance with processes of care.

Background Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast-conserving surgery and improve outcomes for patients, but current practice is unknown and high-quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short-term outcomes of the technique. Methods Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re-excision rates and time to adjuvant therapy. Results Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast-conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise-pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple–areola pedicles were used. Immediate contralateral symmetrization was performed in one-third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16–38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42–66) days. Conclusion Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost-effectiveness.

Trauma patients are at high risk for life-threatening venous thromboembolic (VTE) events. We examined the relationship between prophylactic inferior vena cava (IVC) filter use, mortality, and VTE.The prevalence of prophylactic placement of IVC filters has increased among trauma patients. However, there exists little data on the overall efficacy of prophylactic IVC filters with regard to outcomes.Trauma quality collaborative data from 2010 to 2014 were analyzed. Patients were excluded with no signs of life, Injury Severity Score9, hospitalization3 days, or who received IVC filter after occurrence of VTE event. Risk-adjusted rates of IVC filter placement were calculated and hospitals placed into quartiles of IVC filter use. Mortality rates by quartile were compared. We also determined the association of deep venous thrombosis (DVT) with the presence of an IVC filter, accounting for type and timing of initiation of pharmacological VTE prophylaxis.A prophylactic IVC filter was placed in 803 (2%) of 39,456 patients. Hospitals exhibited significant variability (0.6% to 9.6%) in adjusted rates of IVC filter utilization. Rates of IVC placement within quartiles were 0.7%, 1.3%, 2.1%, and 4.6%, respectively. IVC filter use quartiles showed no variation in mortality. Adjusting for pharmacological VTE prophylaxis and patient factors, prophylactic IVC filter placement was associated with an increased incidence of DVT (OR = 1.83; 95% CI, 1.15-2.93, P-value = 0.01).High rates of prophylactic IVC filter placement have no effect on reducing trauma patient mortality and are associated with an increase in DVT events.

Neoadjuvant treatment offers a number of benefits for patients with early breast cancer, and is an important option for consideration by multidisciplinary teams. Despite literature showing its efficacy, the use of neoadjuvant therapy varies widely. Here we discuss the clinical evidence supporting the use of neoadjuvant therapy in early stage breast cancer, including patient selection, monitoring response, surgery and radiotherapy considerations, with the aim of assisting multidisciplinary teams to determine patient suitability for neoadjuvant treatment.

The use of primary endocrine therapy (PET) in managing breast cancer in the elderly has become common practice. Whilst there appears to be no difference in overall survival in comparison with surgery, PET has been found to be inferior in local disease control with a limited duration of efficacy (2-3 years). The International Society of Geriatric Oncology (SIOG) state that PET may be considered in patients with a short life expectancy (2 years) or considered unfit for surgery. Frequently, decision making for PET allocation is a subjective process by the clinician.A systematic literature review was performed to establish what prediction models are available for all-cause mortality in the elderly, and what breast-specific models have been produced.18 prognostic models were deemed eligible from 15 papers. 1 breast-specific model was found, 2 nursing home related and 15 for community-dwelling elders. Accuracy (as defined by discrimination; c-statistic or AUROC) ranged from 0.69 (moderate) to 0.86 (very good).This review highlighted a variety of validated prognostic indexes. Several models with very good accuracy were identified but most were validated in US-populations and relied on information from administrative datasets. One breast specific model by Stotter et al. was identified, specifically to aid treatment planning for frail elderly patients but had limited accuracy. The strength of an index will ultimately be on its clinical impact and influence on treatment decisions rather than its accuracy and as of yet no trials exploring this have been carried out.

Objective: To evaluate the cost–effectiveness of the following three treatments of uterine fibroids in a population of premenopausal women who wish to preserve their uteri: myomectomy, magnetic resonance-guided focused ultrasound (MRgFUS) and uterine artery embolization (UAE). Materials & methods: A decision analytic Markov model was constructed. Cost–effectiveness was calculated in terms of US$ per quality-adjusted life year (QALY) over 5 years. Two types of costs were calculated: direct costs only, and the sum of direct and indirect (productivity) costs. Women in the hypothetical cohort were assessed for treatment type eligibility, were treated based on eligibility, and experienced adequate or inadequate symptom relief. Additional treatment (myomectomy) occurred for inadequate symptom relief or recurrence. Sensitivity analysis was conducted to evaluate uncertainty in the model parameters. Results: In the base case, myomectomy, MRgFUS and UAE had the following combinations of mean cost and mean QALYs, respectively: US$15,459, 3.957; US$15,274, 3.953; and US$18,653, 3.943. When incorporating productivity costs, MRgFUS incurred a mean cost of US$21,232; myomectomy US$22,599; and UAE US$22,819. Using probabilistic sensitivity analysis (PSA) and excluding productivity costs, myomectomy was cost effective at almost every decision threshold. Using PSA and incorporating productivity costs, myomectomy was cost effective at decision thresholds above US$105,000/QALY; MRgFUS was cost effective between US$30,000 and US$105,000/QALY; and UAE was cost effective below US$30,000/QALY. Conclusion: Myomectomy, MRgFUS, and UAE were similarly effective in terms of QALYs gained. Depending on assumptions about costs and willingness to pay for additional QALYs, all three treatments can be deemed cost effective in a 5-year time frame.

Background Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

To measure the effect of an informational video intervention (IVI) compared to standard care (SC) preparation on anxiety and satisfaction prior to percutaneous cardiovascular procedure (PCVP). A quasi-experimental, randomized, prepost design was used to measure the effect of IVI, provided pre-PCVP, compared with SC only preparation on admission anxiety compared with post the IVI and SC preparation. There were 113 males/72 females, mean age of 61.8 years, assigned to IVI ( n = 94) or SC group ( n = 91). After the preparatory information session, there was no difference between groups on state anxiety (37.6 ± 11.7 vs. 36.3 ± 10.7; z = –.500, p = .617). There was a significant improvement in satisfaction in IVI group (54.23 ± 5.5 vs. 50.7 ± 6.6 ( z = −2.9, p = .003). IVI session improved satisfaction with preparation. Viewing the IVI within hours of a PCVP did not reduce measurable anxiety. Further research may reveal a more ideal viewing time.

Electronic clinical decision support can bring newly published knowledge to the point of care. However, local organizational buy-in, support for team workflows, IT system ease of use and other sociotechnical factors are needed to promote adoption. We successfully implemented a multi-variate cardiac risk stratification model from another institution into ours. We recreated the model and integrated it into our workflow, accessing it from our EHR with patient-specific data and facilitating clinical documentation if the user accepts the model results. Our clinical leaders championed the change and led educational dissemination efforts. We describe the ad-hoc social and technical collaboration needed to build and deploy the tool. The tool complements a clinical initiative within a community of practice, and is correlated with appropriate use of nuclear imaging.

Background Acute kidney injury ( AKI ) occurs commonly after transcatheter aortic valve replacement ( TAVR ) and is associated with markedly increased postoperative mortality. We previously identified plasma metabolites predictive of incident chronic kidney disease, but whether metabolite profiles can identify those at risk of AKI is unknown. Methods and Results We performed liquid chromatography–mass spectrometry–based metabolite profiling on plasma from patients undergoing TAVR and subjects from the community‐based Framingham Heart Study (N=2164). AKI was defined by using the Valve Academic Research Consortium‐2 criteria. Of 44 patients (mean age 82±9 years, 52% female) undergoing TAVR , 22 (50%) had chronic kidney disease and 9 (20%) developed AKI . Of 85 metabolites profiled, we detected markedly concordant cross‐sectional metabolic changes associated with chronic kidney disease in the hospital‐based TAVR and Framingham Heart Study cohorts. Baseline levels of 5‐adenosylhomocysteine predicted AKI after TAVR , despite adjustment for baseline glomerular filtration rate (odds ratio per 1‐ SD increase 5.97, 95% CI 1.62–22.0; P =0.007). Of the patients who had AKI , 6 (66.7%) subsequently died, compared with 3 (8.6%) deaths among those patients who did not develop AKI ( P =0.0008) over a median follow‐up of 7.8 months. 5‐adenosylhomocysteine was predictive of all‐cause mortality after TAVR (hazard ratio per 1‐ SD increase 2.96, 95% CI 1.33–6.58; P =0.008), independent of baseline glomerular filtration rate. Conclusions In an elderly population with severe aortic stenosis undergoing TAVR , metabolite profiling improves the prediction of AKI. Given the multifactorial nature of AKI after TAVR , metabolite profiles may identify those patients with reduced renal reserve.

Robotic vehicles working in unknown environments require the ability to determine their location while learning about obstacles located around them. In this paper a method of solving the SLAM problem that makes use of compressed occupancy grids is presented. The presented approach is an extension of the FastSLAM algorithm which stores a compressed form of the occupancy grid to reduce the amount of memory required to store the set of occupancy grids maintained by the particle filter. The performance of the algorithm is presented using experimental results obtained using a small inexpensive ground vehicle equipped with LiDAR, compass, and downward facing camera that provides the vehicle with visual odometry measurements. The presented results demonstrate that although with our approach the occupancy grid maintained by each particle uses only40%of the data needed to store the uncompressed occupancy grid, we can still achieve almost identical results to the approach where each particle filter stores the full occupancy grid.