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Organs suitable for donation are a scarce resource and maximizing the use of available organs is a priority. We aimed to determine whether there is a supply restricting left digit bias in organs offered and accepted for donors entering a new decade of age.Potential deceased organ donors (n = 105,387) who had any organs offered for transplantation from 2010 to 2019 Organ Procurement and Transplantation Network data were analyzed. Donors were identified 1 year before and after a decade altering birthday.At age 70 there was a 5.4% decrease in the probability of any organ placement compared to 69 (95% CI 1.1-9.7). There was a decrease of 0.25 organs (95% CI 0.13-0.37) after age 70.There was a significant left digit bias in the acceptance of any organs for transplantation at ages 60 and 70 as well as in the acceptance of a kidney at age 70.

BACKGROUND In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program. OBJECTIVE To determine whether penalization was associated with improvement in dialysis center quality. DESIGN Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015-2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined. SETTING United States. PARTICIPANTS Outpatient dialysis centers (n = 5830). MEASUREMENTS Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score. RESULTS There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, -2.5 to 3.2 points]) or 2018 (0.3 point [CI, -2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures. LIMITATION The study could not account for how centers respond to penalization. CONCLUSION Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. PRIMARY FUNDING SOURCE None.

This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.

Neoadjuvant therapy (NAT) is increasingly being used in the management of patients with resectable pancreatic ductal adenocarcinoma (PDAC); however, there is a lack of evidence regarding the benefit among these patients. The aim of this study was to evaluate overall survival (OS) in PDAC patients with resectable disease treated with NAT or upfront resection through instrumental variable (IV) analysis. A national cohort study of resectable PDAC patients in the National Cancer Data Base (2007–2015) treated with either upfront surgery or resection after NAT. Using multivariable modeling and IV methods, OS was compared between those treated with NAT and upfront resection. The IV was hospital-level NAT utilization in the most recent year prior to treatment. The cohort included 16,666 patients (14,012 upfront resection; 2654 NAT) treated at 779 hospitals. Among those treated with upfront resection, 59.9% received any adjuvant therapy. NAT patients had higher median (27.9 months, 95% confidence interval [CI] 26.2–29.1) and 5-year OS (24.1%, 95% CI 21.9–26.3%) compared with those treated with upfront surgery (median 21.2 months, 95% CI 20.7–21.6; 5-year survival 20.9%, 95% CI 20.1–21.7%). After multivariable modeling, NAT was associated with an approximately 20% decrease in the risk of death (hazard ratio [HR] 0.78, 95% CI 0.73–0.84), and this effect was magnified in the IV analysis (HR 0.61, 95% CI 0.47–0.79). In patients with resectable PDAC, NAT is associated with improved survival relative to upfront resection. Given the benefits of multimodality therapy and the challenges in receiving adjuvant therapy, consideration should be given to treating all PDAC patients with NAT.

BACKGROUND: The Hospital Acquired Conditions Reduction Program (HACRP) from the Centers for Medicare and Medicaid Services reduces Medicare payments to hospitals with high rates of HACs by 1% each year. It is not known how the savings accruing to CMS from such penalties compare to savings resulting from a reduction in HACs driven by this program. OBJECTIVE: To compare the reported savings to CMS from financial penalties levied under the HACRP with savings resulting from potential reductions in HACs. DESIGN: We evaluated the association between HACs and 90-day episode spending (adjusted to 2015 dollars). We then estimated potential annual savings to CMS if there was a relative decrease in incidence of all HACs by 1 – 20% and compared them to the actual collected HACRP penalties reported by CMS in 2015. DATA SOURCES: 20% Medicare claims data between January 1, 2009 and September 30, 2014. PARTICIPANTS: Medicare fee-for-service beneficiaries aged 65 – 115 who were discharged from an acute care hospital and who met denominator criteria for any of the eight HACs that comprise the AHRQ Patient Safety Indicator (PSI)-90 score that was targeted under the HACRP (n = 7,707,553). OUTCOME: Total price-standardized 90-day episode spending. RESULTS: All HACs were associated with significant increases in total 90-day episode spending, ranging from $3,183 for iatrogenic pneumothorax to $21,654 for postoperative hip fracture. The total estimated savings to Medicare from potential reduction in all HACs ranged from $2 – 44 million per year, an amount much lower than the $360 million penalties levied upon hospitals per year for HACs. CONCLUSION: The penalties levied under the HACRP far exceed the potential cost savings accruing from a 1–20% reduction in HACs that might result from hospitals’ efforts in response to the program.

“Surprise” out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the ...

Supplemental Digital Content is available in the text., Background. Obesity is a barrier to transplant, reducing access and leading to worse outcomes versus nonobese adults. Most transplant centers in the United States maintain body mass index (BMI) cutoffs to listing for kidney transplantation of 35 to 40 kg/m2. There is little contemporary data on the prevalence of obesity among patients with end-stage kidney disease (ESKD) despite its impact on clinical outcomes and healthcare expenditures. Methods. We utilized data from the US Renal Data System from 2008 to 2016 to identify a prevalent cohort of 1 079 410 patients with ESKD. Linear regression determined trends in the proportion of patients within each category of BMI. We also evaluated geographic variation in rates of obesity and transplantation across the United States. Results. Among the 1 079 410 ESKD patients, the largest cohort of patients were those with obesity (n = 423 270; 39.2%). There were 309 707 (28.7%) patients with an overweight BMI and 274 683 (25.4%) with a normal BMI. The proportion of patients with obesity increased significantly from 36.8% in 2008 to 40.2% in 2016 (trend 0.28; 95% confidence interval, 0.05-0.51). There was significant geographic variation by state with rates of obesity ranging from 32.3% to 45.4% and state transplant rates among those obese patients ranging from 22.5% to 46.8%. There is a weak correlation between states with increased rates of obese ESKD patients and states with an increased obesity transplant rate as indicated with r = 0.40 (P = 0.003). Conclusions. Beneficiaries with obesity are now the largest and fastest growing demographic among patients with ESKD in the United States.

Key Points Question Are there any correlations among different potential domains of quality among adult liver transplant programs? Findings In this cohort study of 114 transplant programs that performed a total of 44 554 transplants, there was no correlation among measures reflecting recipient outcomes (1-year graft and patient survival), program aggressiveness (marginal graft use rate), or waiting list management (waiting list mortality rate). Furthermore, only 2 adult liver transplant programs were found to be in the best performing quartile for all 3 domains concurrently. Meaning These findings suggest that institutional-, regional-, or policy-level interventions to improve transplant program performance in one domain of quality may not be associated with deleterious outcomes in improvement in other potentially related domains., This cohort study examines correlations among different potential domains of quality for US adult liver transplant programs., Importance US liver transplant programs have traditionally been evaluated on 1-year patient and graft survival. However, there is concern that a narrow focus on recipient outcomes may not incentivize programs to improve in other ways that would benefit patients with end-stage liver disease. Objective To determine the correlation among different potential domains of quality for adult liver transplant programs. Design, Setting, and Participants This retrospective cohort study was conducted from 2014 to 2019 among adult liver transplant programs included in the United Network for Organ Sharing and Scientific Registry of Transplant Recipients program-specific reports. Liver transplant programs in the United States completing at least 10 liver transplants per year were included. Data were analyzed from March 2 to August 13, 2020. Main Outcomes and Measures The potential domains of quality examined included recipient outcomes (1-year graft and patient survival), aggressiveness (ie, marginal graft use, defined as the rate of use of donors with body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 40, age older than 65 years, or deceased by cardiac death), and waiting list management (ie, waiting list mortality). The correlation among measures, aggregated at the center level, was evaluated using linear regression to control for mean Model for End Stage Liver Disease–Sodium score at organ allocation. The extent to which programs were able to achieve high quality across multiple domains was also evaluated. Results Among 114 transplant programs that performed a total of 44 554 transplants, the mean (SD) 1-year graft and patient survival was 90.3% (3.0%) with a total range of 75.9% to 96.6%. The mean (SD) waiting list mortality rate was 16.7 (6.1) deaths per 100 person-years, with a total range of 6.3 to 53.0 deaths per 100 person years. The mean (SD) marginal graft use rate was 15.8 (8.8) donors per 100 transplants, with a total range of 0 to 49.3 donors. There was no correlation between 1-year graft and patient survival and waiting list mortality (β = −0.053; P = .19) or marginal graft use (β = −0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease–Sodium scores. There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures. Conclusions and Relevance This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management. These findings suggest that a program’s performance in one domain may be independent and unrelated to its performance on others and that the understanding of factors contributing to these domains is incomplete.

PURPOSE Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. We evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. PATIENTS AND METHODS We merged data from the American Hospital Association’s annual survey on hospital system affiliation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which systems centralized each procedure by calculating the annual proportion of surgeries performed at the highest-volume hospital within each system. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and readmissions after accounting for patient, hospital, and system characteristics. RESULTS The average degree of centralization varied from 25.2% (range, 6.6% to 100%) for colectomy to 71.2% (range, 8.3% to 100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.1% (95% CI, 0.8% to 1.4%) absolute reduction in 30-day mortality after pancreatectomy for each 20% increase in the degree of centralization within systems. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was two times higher in the least centralized systems than in the most centralized systems (8.9% v 3.7%, P < .01). Centralization was not associated with better outcomes for colectomy or proctectomy. CONCLUSION Greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these systems may also present unique opportunities to improve the quality of high-risk cancer care.

The aim of this study was to evaluate whether hospital network participation is associated with improvement in surgical outcomes and spending compared to control hospitals not participating in a network.Hospitals face significant financial and organizational pressures to integrate into networks. It remains unclear whether these business arrangements impact clinical quality or healthcare expenditures.We conducted a longitudinal, quasi-experimental study of 1,981,095 national Medicare beneficiaries (2007-2014) undergoing general, vascular, cardiac, or orthopedic surgery at a network (n = 1868) or non-network (n = 2734) hospital. We tested whether joining a network was associated with improvement in the study outcomes after accounting for overall trends toward better outcomes. We used hierarchical multivariable logistical and linear regression to adjust for patient factors, procedural characteristics, type of admission, and hospital factors.After accounting for patient factors and existing trends toward better outcomes, there was no association between network participation and surgical outcomes. For example, the rates of serious complications were similar between network [11.4%, 95% confidence interval (CI) 11.1%-11.5%] and non-network hospitals (11.2%; 95% CI 11.0%-11.3%; odds ratio 1.00, 95% CI 0.97-1.03, P = 0.92). There was no association between time-in-network and improvement in rates of serious complications during the 8-year study period. For example, after 7 years of network participation, the rate of serious complications in 2014 was 9.6% (95% CI 8.8%-10.4%) in network hospitals versus 9.2% (95% CI 8.5%-9.9%, P = 0.11) in non-network hospitals.Hospital network participation was not associated with improvements in patient outcomes or lower episode payments among Medicare beneficiaries undergoing inpatient surgery.

BACKGROUND: The aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes. METHODS: Data from the Healthcare Cost and Utilization Project’s state inpatient databases was utilized from 2010 – 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes. RESULTS: Institutional ICU NC rates varied significantly (mean: 14%, range: 0.1%–73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%–25%). ICU patients who received NC had significantly lower in-hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48–0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53–0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38–0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4–2.3, P < 0.001). Patients who received follow-up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1–4.2, P < 0.001). CONCLUSIONS: Rates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.

This cohort study examines changes in the number of donated livers and median distance traveled for transplant after the implementation of a new policy for allocating livers from deceased donors.

Importance The Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims. Objective To assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery. Design, Setting, and Participants A retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n = 29 710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n = 25 941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates. Exposures Dual eligibility for Medicare and Medicaid. Main Outcomes and Measures Risk-adjusted all-cause 30-day readmission after surgery. Results There were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12 879 of 25 724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25 724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12 578 of 24 333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24 333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, –1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates. Conclusions and Relevance This study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.

Importance Obesity rates in patients with end-stage kidney disease are rising, contribute to excess morbidity, and limit access to kidney transplant. Despite this, there continues to be controversy around the use of bariatric surgery in this patient population. Objective To determine whether bariatric surgery is associated with improvement in long-term survival among patients with obesity and end-stage kidney disease. Design, Setting, and Participants Retrospective cohort study and secondary analysis of previously collected data from the United States Renal Data System registry (2006-2015). We used Cox proportional hazards analysis to evaluate differences in outcomes for patients receiving bariatric surgery (n = 1597) compared with a matched cohort of nonsurgical patients (n = 4750) receiving usual care. Data were analyzed between September 3, 2019, and November 13, 2019. Exposure Receipt of bariatric surgery. Main Outcomes and Measures All-cause mortality at 5 years. Secondary outcomes included disease-specific mortality and incidence of kidney transplant. Results Surgical and nonsurgical control patients had similar age, demographics, and comorbid disease burden. The mean (SD) age was 49.8 (11.2) years for surgical patients vs 51.7 (11.1) years for nonsurgical patients. Six hundred fifteen surgical patients (38.5%) were black vs 1833 nonsurgical patients (38.6%). Surgery was associated with lower all-cause mortality at 5 years compared with usual care (cumulative incidence, 25.6% vs 39.8%; hazard ratio, 0.69, 95% CI, 0.60-0.78). This was driven by lower mortality from cardiovascular causes at 5 years for patients undergoing bariatric surgery compared with nonsurgical control patients (cumulative incidence, 8.4% vs 17.2%; hazard ratio, 0.51; 95% CI, 0.41-0.65). Bariatric surgery was also associated with an increase in kidney transplant at 5 years (cumulative incidence, 33.0% vs 20.4%; hazard ratio, 1.82; 95% CI, 1.58-2.09). However, at 1 year, bariatric surgery was associated with higher all-cause mortality compared with usual care (cumulative incidence, 8.6% vs 7.7%; hazard ratio, 1.45; 95% CI, 1.13-1.85). Conclusions and Relevance Among patients with obesity and end-stage kidney disease, bariatric surgery was associated with lower all-cause mortality compared with usual care. Bariatric surgery was also associated with an increase in kidney transplant. Bariatric surgery may warrant further consideration in the treatment of patients with obesity and end-stage kidney disease.

This proof-of-concept cohort study evaluates whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone., Key Points Question Is surgeon experience with related procedures associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone? Findings In this proof-of-concept cohort study of 176 043 patients and 1028 surgeons, 54 surgeons (5.3%) met modest annual volume thresholds for pancreaticoduodenectomy. However, increasing related hepatopancreatobiliary case volume was associated with better outcomes for pancreaticoduodenectomy. Meaning These findings suggest that related procedure volumes may be used to inform surgeon-specific, volume-based credentialing standards., Importance Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon’s full scope of practice. Objective To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. Design, Setting, and Participants This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon’s mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019. Main Outcomes and Measures Thirty-day mortality and complications. Results The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies. Conclusions and Relevance In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.

"Surprise" out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013-17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.

BACKGROUND: Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp. METHODS: We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010–2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the Hospital Referral Region (HRR) level, adjusted for age, sex, and race. RESULTS: Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32 to 1.84 per 1,000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01 to 0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope=0.61, 95% CI 0.48 – 0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp. CONCLUSIONS: The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists’ referral practice or skill or surgeons’ decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.

Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians.To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities.Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017.Patient, clinician, and insurance factors potentially related to out-of-network bills.The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service.Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill.In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.

When making health care decisions, patients, their providers, and health care policymakers need evidence on the benefits and harms of different treatment options. Many questions in medicine are not amenable to randomized controlled trials (RCT). The use of observational data, such as insurance claims data, tumor registry data, quality collaborative databases, and clinical registries, to evaluate the comparative effectiveness of various treatment strategies is an attractive alternative. However, causal inference is more difficult in observational studies than in RCTs because patients are not randomly assigned to treatment groups. The objectives of this chapter are to discuss the challenges with using observational data to assess treatment effectiveness and to review methods for enhancing causal inference. Investigators need to identify potential threats to the validity of their results including selection bias, confounding, and measurement bias. Studies that do not account for such threats to validity can produce biased effect estimates that contribute to inappropriate treatment and policy decisions. In this chapter, we focus on careful study design and encourage intimate knowledge of the observational dataset, especially when using administrative data. Finally, we review statistical methods including multivariate analysis, propensity score analysis, and instrumental variable analysis that may be used to adjust for bias and strengthen causal inference. Several clinical examples are provided throughout to demonstrate threats to validity and the statistical methods used to address them.

Fostering successful mentoring relationships is vital to trainees’ development into future leaders in health services research. The right mentors can be hugely beneficial for mentees’ skill acquisition, development and refinement of a career vision, creation and growth of a professional network, and the ability to pursue unique career opportunities. In the new era of mentoring relationships, it is exceedingly rare for mentees to find a “one size fits all” mentor. Instead, mentees should look to establish a network of mentors to fulfill their various professional and personal needs. Appropriate mentor selection depends on both a mentee’s individual goals and identifying a mentor who meshes well with a mentee’s expectations, working style, and personality. Additionally, a successful mentoring relationship largely depends on a mentee’s ability to take charge of the relationship and manage up. While there are several best practice behaviors and mentee missteps to avoid, sometimes even the best mentoring relationships can become unproductive, and it’s important to acknowledge when it’s time to break up with a mentor. Development in academic surgery is a team effort, and finding the right team of mentors is crucial to one’s personal and professional growth.

Few studies have evaluated whether outcome disparities between Medicaid and private insurance beneficiaries are driven by the hospital at which the patient receives care. The purpose of this study was to evaluate the effect of the hospital on surgical outcomes in Medicaid beneficiaries. We identified 139,566 non-elderly Medicaid and private insurance beneficiaries undergoing general, vascular, or gynecological surgery between 2012 and 2017 using a statewide clinical registry in Michigan. We calculated risk-adjusted rates of complications, readmissions, emergency department (ED) visits, and post-acute care utilization using multivariable logistic regression, accounting for patient and procedural factors. We then evaluated whether, and to what extent, the hospital influenced outcome disparities between Medicaid and privately insured beneficiaries. Risk-adjusted rates for all outcomes were higher in Medicaid beneficiaries. For example, overall post-discharge ED visit rates were 14.3% (95% CI 13.7% to 14.9%) for Medicaid compared to 7.5% (95% CI 7.1% to 7.9%, P

OBJECTIVE: To quantify the extent to which payments for laparoscopic and open colectomy are influenced by a surgeon’s experience with laparoscopy. BACKGROUND: Numerous studies suggest that healthcare costs for laparoscopic colectomy are lower than open surgery. None have assessed the importance of surgeon experience on the relative financial benefits of laparoscopy. METHODS: We conducted a study of 182,852 national Medicare beneficiaries undergoing laparoscopic or open colectomy between 2010 and 2012. Using instrumental variable methods to account for selection bias, we compared Medicare payments for laparoscopic and open colectomy. We stratified our analysis by surgeons’ annual experience with laparoscopic colectomy to determine the influence of provider experience on payments. RESULTS: In the fully adjusted analysis, average episode payments per patient were $2640 [95% confidence interval (CI) −$4091 to −$1189] lower with the laparoscopic approach versus open. Surgeons in the highest quartile of laparoscopic experience demonstrated an average payment savings of $5456 per patient (CI −$7918 to −$2994) in their laparoscopic versus open cases. Among surgeons in the lowest quartile of laparoscopic experience, there was, however, no difference between laparoscopic and open cases (difference: $954, 95% CI −$731 to $2639). Differences in payments were explained by differences in complications rates. Both groups had similar rates of complications for open procedures (least experience, 21%, most experience, 21%; P = 0.45), but differed significantly on rates of complications for laparoscopic cases (least experience, 28%, most experience, 15%; P < 0.01). CONCLUSIONS: This population-based study demonstrates that differences in payments between laparoscopic and open colectomy are influenced by surgeon experience. The laparoscopic approach does not reduce payments for patients whose surgeons have limited experience with the procedure.

The Centres for Medicare and Medicaid Services (CMS) announced the Hospital Acquired Conditions Reduction Program (HACRP) in 2013, which penalises the 25% of hospitals in USA with the highest rates of hospital-acquired conditions (HACs). CMS uses two domains to measure the incidence of conditions for this programme—the Agency for Healthcare Research and Quality’s Patient Safety Indicators (PSI-90) (Domain 1) and the National Healthcare Safety Network (NHSN) hospital-associated infection measures (Domain 2). Domain 2 constitutes 85% of the total score used to levy financial penalties against hospitals. The PSI-90 composite is derived from Medicare claims; the NHSN measures are derived from an electronic registry managed by the Centres for Disease Control and Prevention. While many agree that reducing harm from hospitalisations is an important national priority, there are concerns that the PSI-90 composite is not valid,1 2 the NHSN measures may undercount events among hospitals looking to avoid financial penalties,3 and neither have robust auditing mechanisms to ensure data accuracy.4 We used data from the Michigan Surgical Quality Collaborative (MSQC),5 a prospective clinical registry, to replicate the HACRP measures according to publicly available specifications from CMS.6 Data for this registry are collected by trained nurse abstractors and audited regularly to ensure accuracy. We constructed our MSQC clinical registry cohort using the same HACRP measurement periods for Domain 1 (July 1, 2014 to September 30, 2015) and Domain 2 (January 1, 2015 to December 31, 2016). These are the measures and time periods referenced by …

OBJECTIVE We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems. SUMMARY OF BACKGROUND DATA Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost. METHODS Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level. RESULTS Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272-$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545-$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals. CONCLUSIONS Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs.

In 2013 the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the program has been successful in improving patient safety has not been independently evaluated. We used clinical registry data on rates of hospital-acquired conditions in 2010-18 from a large surgical collaborative in Michigan to estimate the impact of the policy. While rates of all such conditions declined from 133.4 per 1,000 discharges in the pre-program period to 122.2 in the post-program period, greater improvements were observed for nontargeted measures. We conclude that the program did not improve patient safety in Michigan beyond existing trends. These findings raise questions about whether the program will lead to improvements in patient safety as intended.

BACKGROUND: Bundled payment programs broaden hospitals’ responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare’s Bundled Payments for Care Improvement-Advanced Program. OBJECTIVE: To evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy. DESIGN: This was a population-based study. SETTINGS: We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014. PATIENTS: We identified patients undergoing colon resections using Diagnosis Related Group codes and International Classification of Disease, Ninth Revision, Clinical Modification codes. MAIN OUTCOME MEASURES: We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010-2014).We projected per-patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared shavings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures. RESULTS: Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of −$234 (95% CI −$245 to −$223). Risk-adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment +$237, 95% CI $96 to $379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be −$472 (95% CI −$506 to −$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI $262 to $326). LIMITATIONS: Alternative payment models for colectomy have not yet been introduced. CONCLUSIONS: Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk-adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared-savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.

Importance The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. Objective To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. Design, Setting, and Participants This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. Exposures Receipt of robotic colectomy. Main Outcomes and Measures Incidence of postoperative medical and surgical complications and length of stay. Results A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). Conclusions and Relevance While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

In the United States, the Centers for Medicare and Medicaid Services (CMS) use Systems Improvement Agreements (SIAs) to require transplant programs repeatedly flagged for poor-performance to improve performance or lose CMS funding for transplants. We identified 14 kidney transplant (KT) programs with SIAs and 28 KT programs without SIAs matched on waitlist volume and characterized kidney acceptance using SRTR data from 12/2006–3/2015. We used difference-in-differences linear regression models to identify changes in acceptance associated with an SIA independent of program variation and trends prior to the SIA. SIA programs accepted 26.9% and 22.1% of offers pre- and post-SIA, while non-SIA programs accepted 33.9% and 44.4% of offers in matched time periods. After adjustment for donor characteristics, time-varying waitlist volume, and secular trends, SIAs were associated with a 5.9 percentage-point (22%) decrease in kidney acceptance (95% CI: −10.9 to −0.8, p=0.03). The decrease in acceptance post-SIA was more pronounced for KDPI 0–40 kidneys (12.3 percentage-point decrease, p=0.007); reductions in acceptance of higher KDPI kidneys occurred pre-SIA. Programs undergoing SIAs substantially reduced acceptance of kidney offers for waitlisted candidates. Attempts to improve post-transplant outcomes might have the unintended consequence of reducing access to transplantation as programs adopt more restrictive organ selection practices.

Enhanced recovery protocols align with the current advantages of laparoscopic donor nephrectomy and may continue to decrease disincentives to donation.In this single-center retrospective analysis, we compare the outcomes of the first 60 living kidney donors enrolled in our enhanced recovery program (ERP) to those patients treated before implementation of the protocol. In addition to improved coordination of care, highlights of the ERP bundle included the use of transversus abdominus plane block, preoperative carbohydrate loading and narcotic free pain regimens. Chi-square and Student t test were used where appropriate.Postoperative median length of stay decreased from 2.0 to 1.0 days (P0.01) after protocol initiation. Overall narcotic use also decreased by nearly 50% (45.6 vs. 21.3; P0.01), whereas pain scores remained similar (3.97 vs. 3.87; P=ns). Average time to incision was longer in the enhanced recovery group as compared to the standard protocol group (51 vs 42 min; P0.05) by 9 min.Implementation of an ERP for living kidney donors was associated with reduced LOS and decreased narcotic use after donor nephrectomy. This study suggests that ERPs may offer a framework for decreasing disincentives for donation and optimize patient satisfaction.