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Background Under bundled payment initiatives, providers will be held financially responsible for patients' acute and post-acute care costs. Certain patients, termed high utilizers, use disproportionate shares of resources during 1 year. The aim of this study was to identify high utilizers, describe their costs, and determine whether preoperative characteristics predict high utilizer status. Study Design Colectomy patients with 1-year follow-up were identified in a linked clinical (American College of Surgeons NSQIP) and administrative (Medicare inpatient claims) dataset (2005 to 2008). Cost of inpatient care was calculated by multiplying patient Medicare charges in each cost center by cost-to-charge ratios from the Medicare cost reports. A mixed-effects logistic model quantified the association between preoperative characteristics and being a high utilizer after elective and emergent colectomies. Results One thousand and fifty-five of 10,561 colectomy patients accounted for >50% of the inpatient care cost of the entire cohort during 1 year postoperatively. This top decile of patients were labeled high utilizers and had substantially greater costs in the following cost centers: intensive care ($36,322 vs $0), respiratory ($2,875 vs $22), radiology ($649 vs $29), and cardiology ($5,057 vs $166) (all p < 0.001). High utilizers more frequently had emergent index colectomies (43% vs 17%; p < 0.001). Patients with American Society of Anesthesiologists class IV and V had 2-fold increased odds of being high utilizers after both elective (odds ratio = 2.72; 95% CI, 1.89-3.90) and emergent colectomies (odds ratio = 2.09; 95% CI, 1.23-3.55). Conclusions Patients in the top cost decile account for the majority of costs in the year after colectomy, disproportionately accumulate those costs in particular cost centers, and can be identified preoperatively.

Background The use of post-acute care is common among the elderly and accounts for $62 billion in annual Medicare expenditures. However, little is known about post-acute care use after surgery. Study Design Data were merged between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare claims for 2005 to 2008. Post-acute care use, including skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and home health care (HHC) were analyzed for 3 operations: colectomy, pancreatectomy, and open abdominal aortic aneurysm repair. Controlling for both preoperative risk factors and the occurrence of postoperative complications, we used multinomial logistic regression to estimate the odds of use for each type of post-acute care after elective surgery compared with home discharge. Results Post-acute care was used frequently for patients undergoing colectomy (40.0%; total n = 10,932), pancreatectomy (46.0%; total n = 2,144), and open abdominal aortic aneurysm (AAA) repair (44.9%; total n = 1,736). Home health was the most frequently reported post-acute care service for each operation (range 23.2% to 31.5%) followed by SNF (range 12.0% to 15.0%), and then by IRF (range 2.5% to 5.4%). The majority of patients with at least 1 inpatient complication were discharged to post-acute care (range 58.6% for open AAA repair to 64.4% for colectomy). In multivariable analysis, specific preoperative risk factors, including advanced age, poor functional status, and inpatient complications were significantly associated with increased risk-adjusted odds of discharge to post-acute care for each operation studied. Conclusions Among elderly patients, post-acute care use is frequent after surgery and is significantly associated with several preoperative risk factors and postoperative inpatient complications. Further work is needed to ensure that post-acute care services are used appropriately and cost-effectively.

Background Currently, hospital benchmarking organizations are often limited to short-term surgical quality comparisons among hospitals. The goal of this study was to determine whether long-term rates of incisional hernia repair after common abdominal operations could be used to compare hospital long-term surgical quality. Study Design This was a cohort study with up to 4 years of follow-up. Patients who underwent 1 of 5 common inpatient abdominal operations were identified in 2005-2008 American College of Surgeons NSQIP data linked to Medicare inpatient records. The main outcomes included occurrence of an incisional hernia repair. A multivariable, shared frailty Cox proportional hazards regression was used to compare each hospital's incisional hernia rate with the overall mean rate for all hospitals and control for American College of Surgeons NSQIP preoperative clinical variables. Results A total of 37,134 patients underwent 1 of 5 common inpatient abdominal operations, including colectomy, small bowel resection, ventral hernia repair, pancreatic resection, or cholecystectomy, at 1 of 216 hospitals participating in American College of Surgeons NSQIP during the 4-year period. There were 1,474 (4.0%) patients who underwent an incisional hernia repair, at a median follow-up time of 16 months (interquartile range 8 to 25 months) after initial abdominal surgery. After risk adjustment, there was no significant difference in the ratio of any one hospital's adjusted hazard rate for incisional hernia repair vs the average hospital adjusted hazard rate. Conclusions Risk-adjusted hospital rates of incisional hernia repair do not vary significantly from the average. This suggests that incisional hernia repair might not be sensitive enough as a long-term quality metric for benchmarking hospital performance.

Background: Patients in rural areas have reduced colonoscopy access, which is critical for colorectal cancer prevention. General surgeons perform most colonoscopies in rural areas. The Surgical Collaborative of Wisconsin's Rural Task Force identified colonoscopy as a high priority initiative due to high volume and lack of quality measure access, both necessary for assessing and improving performance., Objective: Assess the capacity for colonoscopy quality measurement and improvement in rural Wisconsin hospitals., Design: In October 2019-January 2020, the Surgical Collaborative of Wisconsin, Rural Wisconsin Health Cooperative, and Wisconsin Collaborative for Healthcare Quality collaborated to design/distribute a survey to 44 Rural Wisconsin Health Cooperative hospitals (n = 25 completed, response rate 57%). Descriptive statistics summarized survey items. Surgeons in each of six rural hospitals participated in stakeholder interviews., Setting: Rural Wisconsin Health Cooperative hospitals., Main Outcome Measures: Colonoscopy providers, procedure volume/capacity, informatics and quality measurement infrastructure, barriers to quality measurement and improvement., Results: Most colonoscopy providers in rural hospitals were surgeons (66.3%) followed by family/internal medicine (20.0%) and gastroenterologists (13.8%). Average hospital volume/week was 19.9 colonoscopies (SD = 13.4). Hospitals reported operating at ~75% capacity. Withdrawal time was the most tracked measure (44.0%), followed by adenoma detection (36.0%), and cecal intubation (28.0%) rates. Approximately one-third of hospitals (36.0%) utilized procedure reporting software. Most hospitals (80.0%) did not have access to onsite pathology. Surgeons reported barriers to quality measurement/improvement, including insufficient resources for electronic medical record-based reporting and the need for targeted educational opportunities that do not require travel., Limitations: Single state; may not represent experience of all rural hospitals., Conclusions: The lack of access to colonoscopy quality measures suggests the opportunity to develop a flexible approach that considers reporting software availability and electronic medical record differences. Improving access to measures and education/training opportunities may improve availability of high-quality colonoscopy for patients in rural Wisconsin. See Video Abstract., (Copyright © The ASCRS 2024.)

Background: Although squamous cell carcinoma of the anus (SCCA) is a relatively uncommon malignancy in the United States, it continues to increase in incidence. Treatment for locoregional disease includes mitomycin and 5-fluorouracil with radiation. This combination is associated with significant toxicity, limiting its use in patients who are older or have certain comorbidities. Carboplatin and paclitaxel (C/P) is an accepted treatment regimen for metastatic SCCA. We aim to evaluate the efficacy and toxicity of weekly C/P given with radiation for patients unable to receive standard chemoradiation for SCCA., Methods: From our cancer registry, adult patients who received weekly intravenous C/P concurrent with standard-dose radiation for localized SCCA were included in this study. Clinical response was determined based on the evidence of disease on imaging and/or anoscopy. Toxicities were graded according to the CTCAE v5., Results: Ten patients were included; eight were female, and the median age was 75.5 years (54-87). Six had T2 disease, and four had T3 tumors. Four had node-positive disease. The majority (70%) of patients were dosed at standard C (AUC 2) and P (50 mg/m 2 ), with a limited subset requiring dose reduction for baseline performance status. Patients completed a mean of 78.3% (40-100%) of the intended treatments. A total of 89% of the patients achieved a complete clinical response. With a median follow-up of 25.8 months (3.4-50.4 months), 67% of the patients are alive and without recurrence. Two patients have had local recurrence, and one patient had metastatic progression. The most common toxicities of any grade included leukopenia (100%), anemia (100%), radiation dermatitis (100%), diarrhea (100%), and fatigue (100%). Grade 3 or higher toxicities included neutropenic fever (20%), neutropenia (30%), and anemia (30%)., Conclusions: This study demonstrates promising tolerability and efficacy for weekly C/P chemoradiation for patients with anal cancer unable to receive mitomycin and 5-fluorouracil. This regimen merits further investigation in prospective clinical trials.

Objective: Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates., Background: Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target., Methods: Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided., Results: In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91)., Conclusions: Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Management of patients with rectal cancer can be complex, requiring significant care coordination and decisions that balance functional and oncologic outcomes., Objective: To characterize care coordination occurring during surgical consultation for rectal cancer and consequences of using face-to-face time in clinic for care coordination., Methods: Secondary analysis was performed on audio recordings of clinic visits with colorectal surgeons to discuss surgery for rectal cancer at 5 academic medical centers. Analysis included the content of communication related to types of care coordination, specific details and conditions under which care coordination was conducted, and consequences., Results: The cohort included 18 patients seen by 8 surgeons. Care coordination consumed much of the conversation; on average 23.7% (SD 14.6) of content. Communication about care coordination included gathering information from work-up already performed, logistics for completing further work-up, gathering multidisciplinary opinions, and logistics for treatment planning. Obtaining imaging results was particularly challenging and surgeons went to great lengths to gather this information. To mitigate information gaps, surgeons asked patients about critical clinical details. Patients expressed remorse when they could not provide needed information, relay technical details, or had missing reports. Surgeons voiced frustration at the system related to the need to gather information from multiple sources and coordinate logistics. Surgeons worked to inform patients about their disease and discuss important lifestyle and cancer-related tradeoffs. However, the ability to solicit patient input and engage in shared decision making was often limited by incomplete data or conditioned on approval by a multidisciplinary tumor board., Conclusion: Much of the conversation between surgeons and patients with rectal cancer is consumed by care coordination. Organizing care coordination outside of the clinic visit would likely improve the experience for both patients and surgeons, addressing both clinician burnout and variation in management and outcomes., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS)., Study Design: In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement., Results: In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds., Conclusions: Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Surgeons.)

Background: The Department of Veterans Affairs cares for the largest population of patients with HIV of any healthcare system in the United States. Screening for anal dysplasia/cancer is recommended for all veterans with HIV. Exams are invasive, burdensome, and resource intensive. We currently lack markers of disease to tailor screening., Objective: The purpose of this study was to establish the prevalence of advanced anal disease (high-grade dysplasia and anal cancer) and to determine whether CD4/CD8 ratio correlates with risk., Design: This was a retrospective regional cohort study of veterans with HIV., Settings: The study was conducted at eight medical centers between 2001 and 2019., Patients: Patients with advanced disease were compared with patients with nonadvanced anal pathology., Main Outcome Measures: Logistic regression modeling was used to estimate adjusted odds of disease as a function of CD4/CD8. Lowest (nadir) CD4/CD8 and nearest CD4/CD8 ratio in each cohort were evaluated., Results: A total of 2267 veterans were included. Fifteen percent had anal pathology (112 with advanced disease (37 cancer and 75 high-grade), 222 with nonadvanced disease). Nadir and nearest ratio were lower in patients with advanced disease versus nonadvanced (0.24 vs 0.45 (p < 0.001) and 0.50 vs 0.88 (p < 0.001)). In adjusted models, a 1-unit increase in nadir or nearest ratio conferred decreased risk of advanced disease (OR = 0.19 (95% CI, 0.07-0.53); p < 0.001; OR = 0.22 (95% CI, 0.12-0.43); p < 0.001). Using a minimum sensitivity analysis, a cutoff nadir ratio of 0.42 or nearest ratio of 0.76 could be used to risk stratify., Limitations: This was a retrospective analysis with a low screening rate., Conclusions: In a regional cohort of veterans with HIV, 15% were formally assessed for anal dysplasia. Advanced anal disease was present in 33% of those screened, 5% of the HIV-positive population. A strong predictor of advanced disease in this cohort is the CD4/CD8 ratio, which is a promising marker to stratify screening practices. Risk stratification using CD4/CD8 has the potential to decrease burdensome invasive examinations for low-risk patients and to intensify examinations for those at high risk. See Video Abstract at http://links.lww.com/DCR/B528., Prevalencia De Displasia Anal De Alto Grado Y Cncer Anal En Veteranos Que Viven Con El Vih Y La Relacin Cd / Cd Como Marcador De Mayor Riesgo Un Estudio De Cohorte Regional Retrospective: ANTECEDENTES:El Departamento de Asuntos de Veteranos atiende a la población más grande de pacientes con el virus de inmunodeficiencia humana (VIH) de cualquier sistema de salud en los Estados Unidos. Se recomienda la detección de displasia / cáncer anal para todos los veteranos con VIH. Los exámenes son invasivos, onerosos y requieren muchos recursos. Actualmente carecemos de marcadores de enfermedad para adaptar la detección.OBJETIVO:Establecer la prevalencia de enfermedad anal avanzada (displasia de alto grado y cáncer anal) y determinar si la relación CD4 / CD8 se correlaciona con el riesgo.DISEÑO:Estudio de cohorte regional retrospectivo de veteranos con VIH.AJUSTE:Ocho centros médicos entre 2001-2019.PACIENTES:Se comparó a pacientes con enfermedad avanzada con pacientes con patología anal no avanzada.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó un modelo de regresión logística para estimar las probabilidades ajustadas de enfermedad en función de CD4 / CD8. Se evaluó la relación CD4 / CD8 más baja (nadir) y la relación CD4 / CD8 más cercana en cada cohorte.RESULTADOS:Se incluyeron un total de 2267 veteranos. El 15% tenía patología anal (112 enfermedad avanzada (37 cáncer, 75 de alto grado), 222 enfermedad no avanzada). El nadir y el cociente más cercano fueron menores en los pacientes con enfermedad avanzada frente a los no avanzados (0,24 frente a 0,45 (p <0,001) y 0,50 frente a 0,88 (p <0,001)), respectivamente. En modelos ajustados, el aumento de una unidad en el nadir o el cociente más cercano confirió una disminución del riesgo de enfermedad avanzada (OR 0,19 (IC del 95%: 0,07, 0,53, p <0,001)) y (OR 0,22 (IC del 95%: 0,12, 0,43, p <0,001))), respectivamente. Utilizando un análisis de sensibilidad mínima, se podría utilizar un cociente del nadir de corte de 0,42 o el cociente más cercano de 0,76 para estratificar el riesgo.LIMITACIONES:Análisis retrospectivo con una tasa de detección baja.CONCLUSIONES:En una cohorte regional de veteranos con VIH, el 15% fueron evaluados formalmente por displasia anal. La enfermedad anal avanzada estuvo presente en el 33% de los examinados, el 5% de la población VIH +. Un fuerte predictor de enfermedad avanzada en esta cohorte es la relación CD4 / CD8, que es un marcador prometedor para estratificar las prácticas de detección. La estratificación del riesgo usando CD4 / CD8 tiene el potencial de disminuir los exámenes invasivos onerosos para los pacientes de bajo riesgo e intensificar los exámenes para los de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B528.

Background: Surgeons contribute to the opioid epidemic by overprescribing opioids for postoperative pain. Excess, unused opioids may be diverted for misuse/abuse., Objective: This study aimed to characterize opioid prescribing and use among patients undergoing outpatient anorectal procedures and to assess the adequacy of postoperative pain management., Design: This is a retrospective cohort study, prospective cross-sectional survey., Settings: Patients were treated by colorectal surgeons in an academic medical center between January 2018 and September 2019., Patients: Six hundred twenty-seven patients undergoing an outpatient anorectal procedure were included., Main Outcome Measures: The primary outcomes measured were the opioids prescribed at discharge, opioid prescription refills, patient-reported outcomes regarding opioid use, and the adequacy of postoperative pain management in terms of pain intensity and pain interference. Opioids were standardized to 5-mg oxycodone pills. Patient-reported outcomes were assessed by using previously validated instruments., Results: The majority of patients underwent fistula surgery (n = 234) followed by examination under anesthesia (n = 183), hemorrhoidectomy (n = 131), incision and drainage (n = 51), and pilonidal excision (n = 28). Most patients received opioids (78% fistula, 49% examination under anesthesia, 87% hemorrhoidectomy, 71% incision and drainage, 96% pilonidal). Patients undergoing examination under anesthesia received the fewest opioid pills (median 10; range 3-50) followed by patients undergoing fistula surgery (median13, range 1-50), incision and drainage (median 15, range 3-120), pilonidal excisions (median 15, range 3-60), and hemorrhoidectomies (median 28, range 3-60). Regardless of procedure, the majority of patients used fewer than 5 opioid pills postoperatively. Patients undergoing pilonidal excisions had the largest number of excess unused pills (median 14, range 0-30) followed by patients undergoing fistula surgery and incision and drainage (median 7, ranges 0-30 and 5-17), hemorrhoidectomy (median 6, range 0-50), and examination under anesthesia (median 2, range 0-23). Whereas patients undergoing hemorrhoidectomy reported higher pain levels following discharge, most reported minimal interference with day-to-day activities due to pain regardless of the procedure performed., Limitations: The limitations of this study included recall bias and sample bias., Conclusions: The majority of patients do not need more than five to ten 5-mg oxycodone equivalents to achieve adequate pain management after outpatient anorectal surgical procedures. See Video Abstract at http://links.lww.com/DCR/B347. EXCESO DE PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE UNA CIRUGÍA ANORRECTAL AMBULATORIA: UN ESTUDIO DE UNA SOLA INSTITUCIÓN: Cirujanos contribuyen a la epidemia de opioides al recetar en exceso opioides para el dolor postoperatorio. El exceso de opioides no utilizados puede ser desviado por para mal uso o abuso.Caracterizar la prescripción y el uso de opioides entre pacientes sometidos a procedimientos anorrectales ambulatorios y evaluar la efectividad del tratamiento del dolor postoperatorio.Estudio de cohorte retrospectivo, encuesta transversal prospectiva.pacientes tratados por cirujanos colorrectales en un centro médico académico entre enero de 2018 y septiembre de 2019.se incluyeron 627 pacientes que se sometieron a un procedimiento anorrectal ambulatorio.Opioides recetados al alta, reabastecimientos de prescripción de opioides, resultados informados por el paciente con respecto al uso de opioides y efectividad del manejo del dolor postoperatorio en términos de intensidad del dolor y trastornos secundarios a dolor. Los opioides se estandarizaron con píldoras de oxicodona de 5 mg. Los resultados informados por los pacientes se evaluaron utilizando instrumentos previamente validados.La mayoría de los pacientes fueron sometidos a cirugía de fístula (n = 234) seguida de un examen bajo anestesia (EUA; n = 183), hemorroidectomía (n = 131), incisión y drenaje (I&D) (n = 51) y escisión pilonidal (n = 28). La mayoría de los pacientes recibieron opioides (78% fístula, 49% EUA, 87% hemorroidectomía, 71% I&D, 96% pilonidal). Las EUA recibieron la menor cantidad de píldoras opioides (mediana 10, rango 3-50) seguidas de fístula (mediana 13, rango 1-50), I y D (mediana 15, rango 3-120), pilonidales (mediana 15, rango 3-60) y hemorroides. (mediana 28, rango 3-60). Independientemente del procedimiento, la mayoría de los pacientes usaron menos de cinco píldoras opioides después de la operación. Los pacientes pilonidales tuvieron el mayor número de píldoras no utilizadas en exceso (mediana 14, rango 0-30) seguido de fístula e I&D (mediana 7, rangos 0-30 y 5-17, respectivamente), hemorroidectomía (mediana 6, rango 0-50) y EUA (mediana 2, rango 0-23). Si bien los pacientes con hemorroidectomía informaron niveles de dolor más altos después del alta, la mayoría de pacientes informaron un mínimo de interferencia con las actividades diarias debido al dolor, independientemente del procedimiento realizado.Sesgo de recuerdo autoinformado, sesgo de muestra.La mayoría de los pacientes no necesitan más de cinco a diez equivalentes de oxicodona de 5 mg para lograr un manejo adecuado del dolor después de procedimientos quirúrgicos anorrectales ambulatorios. Consulte Video Resumen en http://links.lww.com/DCR/B347. (Traducción-Dr. Adrian Ortega).

Background: Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes., Methods: Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured., Results: A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028)., Conclusion: In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention., (Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Anal cytology is used as a screening tool in the detection of precancerous anal squamous lesions. Follow-up clinical examination after abnormal anal cytology is recommended. The objective of this study was to determine how often abnormal cytology was followed by a clinical examination at our institution and how often cytology predicted histologic outcome., Materials and Methods: A retrospective chart review was performed (2008-2018) on patients with anal cytology, demonstrating either low-grade or high-grade squamous intraepithelial lesion. Clinical examination within 1 y (digital rectal examination, anoscopy, or high-resolution anoscopy) was recorded. The probability of anal intraepithelial neoplasm on biopsy after dysplasia on cytology was calculated, and McNemar's test was used to determine if there was correspondence between cytology and histology., Results: A total of 327 anal cytology results demonstrated dysplasia (75% low grade and 25% high grade) in 182 patients. Seventy-five percent of dysplastic anal cytology were followed by clinical examination within 1 y, and 50% were biopsied. The probability of dysplasia on histology after dysplasia on cytology was 72% (95% confidence interval: 64%-78.5%). Twenty-eight percent of low-grade cytology results were upgraded to advanced disease (high-grade or invasive cancer) on histology. A low-grade cytology result was unable to preclude high-grade histology in our population., Conclusions: There is room for improvement at our institution to consistently follow-up with clinical examination after abnormal anal cytology. Our data suggest this is especially important considering anal cytology is an imperfect predictor of histologic anal intraepithelial neoplasia and invasive disease. Clinical examination is a critical component of anal dysplasia screening and follow-up., (Published by Elsevier Inc.)

Background: Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear., Methods: Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments., Results: 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000., Conclusion: MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: ACS-NSQIP classifies hospitals as "high outliers" if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers., Methods: Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008-2011 for 13 postoperative adverse events. Pearson correlation and R 2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate., Results: Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance., Conclusions: Outlier status may be less meaningful for adverse events with relatively few outlier hospitals., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Little is known about hospital use of postacute care after surgery and whether it is related to measures of surgical quality., Research Design: We used data merged between a national surgery registry, Medicare inpatient claims, the Area Resource File, and the American Hospital Association Annual Survey (2005-2008). Using bivariate and multivariate analyses, we calculated hospital-level, risk-adjusted rates of postacute care use for both inpatient facilities (IF) and home health care (HHC), and examined the association of these rates with hospital quality measures, including mortality, complications, readmissions, and length of stay., Results: Of 112,620 patients treated at 217 hospitals, 18.6% were discharged to an IF, and 19.9% were discharged with HHC. Even after adjusting for differences in patient and hospital characteristics, hospitals varied widely in their use of both IF (mean, 20.3%; range, 2.7%-39.7%) and HHC (mean, 22.3%; range, 3.1%-57.8%). A hospital's risk-adjusted postoperative mortality rate or complication rate was not significantly associated with its use of postacute care, but higher 30-day readmission rates were associated with higher use of IF (24.1% vs. 21.2%, P=0.03). Hospitals with longer average length of stay used IF less frequently (19.4% vs. 24.4%, P<0.01)., Conclusions: Hospitals vary widely in their use of postacute care. Although hospital use of postacute care was not associated with risk-adjusted complication or mortality rates, hospitals with high readmission rates and shorter lengths of stay used inpatient postacute care more frequently. To reduce variations in care, better criteria are needed to identify which patients benefit most from these services.

Objective: To examine the validity of hybrid quality measures that use both clinical registry and administrative claims data, capitalizing on the strengths of each data source., Background: Previous studies demonstrate substantial disagreement between clinical registry and administrative claims data on the occurrence of postoperative complications. Clinical data have greater validity than claims data for quality measurement but can be burdensome for hospitals to collect., Methods: American College of Surgeons National Surgical Quality Improvement Program records were linked to Medicare inpatient claims (2005-2008). National Quality Forum-endorsed risk-adjusted measures of 30-day postoperative complications or death assessed hospital quality for patients undergoing colectomy, lower extremity bypass, or all surgical procedures. Measures use hierarchical multivariable logistic regression to identify statistical outliers. Measures were applied using clinical data, claims data, or a hybrid of both data sources. Kappa statistics assessed agreement on determinations of hospital quality., Results: A total of 111,984 patients participated from 206 hospitals. Agreement on hospital quality between clinical and claims data was poor. Hybrid models using claims data to risk-adjust complications identified by clinical data had moderate agreement with all clinical data models, whereas hybrid models using clinical data to risk-adjust complications identified by claims data had routinely poor agreement with all clinical data models., Conclusions: Assessments of hospital quality differ substantially when using clinical registry versus administrative claims data. A hybrid approach using claims data for risk adjustment and clinical data for complications may be a valid alternative with lower data collection burden. For quality measures focused on postoperative complications to be meaningful, such policies should require, at a minimum, collection of clinical outcomes data.

Importance: The Centers for Medicare and Medicaid Services include patient experience as a core component of its Value-Based Purchasing program, which ties financial incentives to hospital performance on a range of quality measures. However, it remains unclear whether patient satisfaction is an accurate marker of high-quality surgical care., Objective: To determine whether hospital performance on a patient satisfaction survey is associated with objective measures of surgical quality., Design, Setting, and Participants: Retrospective observational study of participating American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) hospitals. We used data from a linked database of Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare from December 2, 2004, through December 31, 2008. A total of 103 866 patients older than 65 years undergoing inpatient surgery were included. Hospitals were grouped by quartile based on their performance on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Controlling for preoperative risk factors, we created hierarchical logistic regression models to predict the occurrence of adverse postoperative outcomes based on a hospital's patient satisfaction scores., Main Outcomes and Measures: Thirty-day postoperative mortality, major and minor complications, failure to rescue, and hospital readmission., Results: Of the 180 hospitals, the overall mean patient satisfaction score was 68.0% (first quartile mean, 58.7%; fourth quartile mean, 76.7%). Compared with patients treated at hospitals in the lowest quartile, those at the highest quartile had significantly lower risk-adjusted odds of death (odds ratio = 0.85; 95% CI, 0.73-0.99), failure to rescue (odds ratio = 0.82; 95% CI, 0.70-0.96), and minor complication (odds ratio = 0.87; 95% CI, 0.75-0.99). This translated to relative risk reductions of 11.1% (P = .04), 12.6% (P = .02), and 11.5% (P = .04), respectively. No significant relationship was noted between patient satisfaction and either major complication or hospital readmission., Conclusions and Relevance: Using a national sample of hospitals, we demonstrated a significant association between patient satisfaction scores and several objective measures of surgical quality. Our findings suggest that payment policies that incentivize better patient experience do not require hospitals to sacrifice performance on other quality measures.

Background: Existing large clinical registries capture short-term follow-up. Yet, there are many important long-term outcomes in surgery, such as recurrence of a ventral hernia after ventral hernia repair. The goal of the current study was to conduct an exploratory analysis to determine whether the rates, timing, and risk factors for ventral hernia re-repair in claims data linked to registry data were consistent with the known clinical literature., Study Design: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare inpatient claims linked data set from 2005 to 2008 was queried to identify ventral hernia re-repairs after index ventral hernia repairs. Survival analysis was used to examine the ventral hernia re-repair rate over time and to quantify the relationship with clinical variables., Results: Of 3,730 index ventral hernia repairs identified in ACS-NSQIP, 247 patients (6.6%) underwent re-repair of a ventral hernia during the study period (2005-2008) in the Medicare claims data. ACS-NSQIP clinical variables that were associated with the ventral hernia re-repair rate in Medicare claims data 1 year after index ventral hernia repair were being a smoker (hazard ratio [HR] = 1.70, P = .02), body mass index (HR = 1.16, P = .04), and postoperative superficial surgical-site infection (HR = 2.88, P < .001)., Conclusion: Long-term rate and timing of ventral hernia re-repair obtained from claims data were an underestimate compared with clinical studies. Yet, several known clinical risk factors for recurrence in the clinical registry were associated with the re-repair rate in claims data at one year. It may be possible to study certain long-term outcomes using selected reoperation rates using the technique of linked clinical registry-claims data, with an understanding that event rates are conservative estimates., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: This study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care., Study Design: Patient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression., Results: There were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p < 0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs., Conclusions: The hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the classification of hospital statistical outlier status as better or worse performance than expected for postoperative complications using Medicare claims versus clinical registry data., Background: Controversy remains as to the most favorable data source for measuring postoperative complications for pay-for-performance and public reporting polices., Methods: Patient-level records (2005-2008) were linked between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare inpatient claims. Hospital statistical outlier status for better or worse performance than expected was assessed using each data source for superficial surgical site infection (SSI), deep/organ-space SSI, any SSI, urinary tract infection, pneumonia, sepsis, deep venous thrombosis, pulmonary embolism, venous thromboembolism, and myocardial infarction by developing hierarchical multivariable logistic regression models. Kappa statistics and correlation coefficients assessed agreement between the data sources., Results: A total of 192 hospitals with 110,987 surgical patients were included. Agreement on hospital rank for complication rates between Medicare claims and ACS-NSQIP was poor-to-moderate (weighted κ: 0.18-0.48). Of hospitals identified as statistical outliers for better or worse performance by Medicare claims, 26% were also identified as outliers by ACS-NSQIP. Of outliers identified by ACS-NSQIP, 16% were also identified as outliers by Medicare claims. Agreement between the data sources on hospital outlier status classification was uniformly poor (weighted κ: -0.02-0.34)., Conclusions: Despite using the same statistical methodology with each data source, classification of hospital outlier status as better or worse performance than expected for postoperative complications differed substantially between ACS-NSQIP and Medicare claims.

Objective: To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost)., Background: Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost., Methods: Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure., Results: The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P < 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations., Conclusions: Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.

Background: Identifying iatrogenic injuries using existing data sources is important for improved transparency in the occurrence of intraoperative events. There is evidence that procedure codes are reliably recorded in claims data. The objective of this study was to assess whether concurrent splenic procedure codes in patients undergoing colectomy procedures are reliably coded in claims data as compared with clinical registry data., Study Design: Patients who underwent colectomy procedures in the absence of neoplastic diagnosis codes were identified from American College of Surgeons (ACS) NSQIP data linked with Medicare inpatient claims data file (2005 to 2008). A κ statistic was used to assess coding concordance between ACS NSQIP and Medicare inpatient claims, with ACS NSQIP serving as the reference standard., Results: A total of 11,367 colectomy patients were identified from 212 hospitals. There were 114 patients (1%) who had a concurrent splenic procedure code recorded in either ACS NSQIP or Medicare inpatient claims. There were 7 patients who had a splenic injury diagnosis code recorded in either data source. Agreement of splenic procedure codes between the data sources was substantial (κ statistic 0.72; 95% CI, 0.64-0.79). Medicare inpatient claims identified 81% of the splenic procedure codes recorded in ACS NSQIP, and 99% of the patients without a splenic procedure code., Conclusions: It is feasible to use Medicare claims data to identify splenic injuries occurring during colectomy procedures, as claims data have moderate sensitivity and excellent specificity for capturing concurrent splenic procedure codes compared with ACS NSQIP., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Rates of hospital readmission are currently used for public reporting and pay for performance. Colectomy procedures account for a large number of readmissions among operative procedures. Our objective was to compare the importance of 3 groups of clinical variables (demographics, preoperative risk factors, and postoperative complications) in predicting readmission after colectomy procedures., Methods: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Patient demographics (n = 2), preoperative risk factors (n = 23), and 30-day postoperative complications (n = 17) were identified from ACS-NSQIP, whereas 30-day postoperative readmissions and costs were determined from Medicare. Multivariable logistic regression models were used to examine risk-adjusted predictors of colectomy readmission., Results: Among 12,981 colectomy patients, the 30-day postoperative readmission rate was 13.5%. Readmitted patients had slightly greater rates of comorbidities and indicators of clinical severity and substantially greater rates of complications than non-readmitted patients. After risk adjustment, patients with a complication were 3.3 times as likely to be readmitted as patients without a complication. Among individual complications, progressive renal failure and organ-space surgical site infection had the highest risk-adjusted relative risks of readmission (4.6 and 4.0, respectively). Demographic, preoperative risk factor, and postoperative complication variables increased the ability to discriminate readmissions (reflected by the c-statistic) by 5.3%, 23.3%, and 35.4%, respectively., Conclusion: Postoperative complications after colectomy are more predictive of readmission than traditional risk factors. Focusing quality improvement efforts on preventing and managing postoperative complications may be the most important step toward reducing readmission rates., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: To determine whether risk-adjusted colorectal SSI rates are statistically reliable as hospital quality measures., Background: Policymakers use surgical site infections (SSI) for public reporting of hospital quality and pay-for-performance because they are a relatively common and costly cause of patient morbidity., Methods: Patients who underwent a colorectal procedure in 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We developed hierarchical multivariate logistic models for (1) superficial SSI, (2) deep/organ-space SSI, and (3) "any SSI" and compared how each model ranked hospital-level risk-adjusted performance. Statistical reliability of hospital quality measurements was estimated on a scale from 0 to 1; with 0 indicating that apparent variation between a hospital's quality measurement and the average hospital is statistically unreliable, and 1 indicating that any observed variation is due to a real difference in performance., Results: Mean reliability of hospital-level quality measurements was 0.650 for superficial, 0.404 for deep/organ-space, and 0.586 for "any SSI." Lower reliability was accounted for by relatively little variation in risk-adjusted SSI rates between hospitals and insufficient numbers of colorectal cases submitted by individual hospitals. In 2009, we estimate that 22.1% of all US hospitals performed a sufficient number of colorectal cases to report superficial SSI rates at a high standard of statistical reliability and 1.0% did for deep/organ-space SSI., Conclusions: As currently constructed, colorectal SSI quality measures might not meet a high standard of statistical reliability for most hospitals, limiting their ability to confidently differentiate high and low performance. Despite an expectation of improving statistical power, combining superficial and deep/organ-space SSI into an "any SSI" measure worsens reliability.

Importance: Surgical site infections (SSIs) are the focus of numerous quality improvement initiatives because they are a common and costly cause of potentially preventable patient morbidity. Superficial and deep/organ-space SSIs differ in terms of anatomical location and clinical severity., Objective: To identify risk factors that are uniquely predictive of superficial vs deep/organ-space SSIs occurring after colectomy procedures., Design: Retrospective cohort study., Setting: American College of Surgeons National Surgical Quality Improvement Program., Participants: Patients undergoing colectomy procedures in 2011 were identified by Current Procedural Terminology codes., Intervention: Colectomy procedures., Main Outcomes and Measures: We compared rates of superficial SSI and deep/organ-space SSI associated with perioperative variables of interest: demographics; preoperative clinical severity, risk factors, and comorbidities and variables related to the hospitalization or procedure. Hierarchical multivariable logistic regression models were developed to identify risk-adjusted predictors of each SSI type., Results: Among 27 011 patients identified from 305 hospitals, 6.2% developed a superficial SSI and 4.7% developed a deep/organ-space SSI. Risk factors common to the occurrence of both SSI types were identified: open surgery (vs laparoscopic) and current smoker. Risk factors with differential effects on each SSI type included specific postoperative diagnoses, disseminated cancer, and irradiation therapy, which were all associated with increased odds of deep/organ-space SSI only. The graded relationship between increasing body mass index and SSI occurrence appeared to be stronger for superficial SSI., Conclusions and Relevance: Risk factors for superficial SSI and deep/organ-space SSI vary in terms of magnitude and significance, suggesting that these SSI types are somewhat different disease processes. Groups interested in preventing SSIs might improve success by considering these SSI types independently for root-cause analyses and development of best practices and interventions.

Objective: To estimate the effect of preventing postoperative complications on readmission rates and costs., Background: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions., Methods: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure., Results: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year., Conclusions: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.

Objective: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure., Background: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target., Methods: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds., Results: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008., Conclusions: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Background: A variety of data sources are available for measuring the quality of health care. Linking records from different sources can create unique and powerful databases that can be used to evaluate clinically relevant questions and direct health care policy. The objective of this study was to develop and validate a deterministic linkage algorithm that uses indirect patient identifiers to reliably match records from a surgical clinical registry with Medicare inpatient claims data., Methods: Patient records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), years 2005-2008, were linked to claims data in the Medicare Provider Analysis and Review file (MedPAR) by the use of a deterministic linkage algorithm and the following indirect patient identifiers: hospital, age, sex, diagnosis, procedure and dates of admission, discharge, and procedure. We validated the linkage procedure by systematically reviewing subsets of matched and unmatched records and by determining agreement on patient-level coding of inpatient mortality., Results: Of the 150,454 records in ACS-NSQIP eligible for matching, 80.5% were linked to a MedPAR record. This percentage is within the expected match range given the estimated percentage of ACS-NSQIP patients likely to be Medicare beneficiaries. Systematic checks revealed no evidence of bias in the linkage procedure and there was excellent agreement on patient-level coding of mortality (kappa 0.969). The final linked database contained 121,070 patient records from 217 hospitals., Conclusion: This study demonstrates the feasibility and validity of a method for linking 2 data sources without direct personal identifiers. As clinical registries and other data sources continue to proliferate, linkage algorithms such as described here will be critical for quality measurement purposes., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objectives: To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry., Background: Policymakers are increasingly discussing use of postoperative complication rates for value-based purchasing. There is debate regarding the optimal data source for such measures., Methods: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient and outpatient claims data sets. We assessed the ability of (1) Medicare inpatient claims and (2) Medicare inpatient and outpatient claims to detect a core set of ACS-NSQIP 30-day postoperative complications: superficial surgical site infection (SSI), deep/organ-space SSI, any SSI (superficial and/or deep/organ-space), urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, venous thromboembolism (DVT and/or pulmonary embolism), and myocardial infarction. Agreement of patient-level complications by ACS-NSQIP versus Medicare was assessed by κ statistics., Results: A total of 117,752 patients from more than 200 hospitals were studied. The sensitivity of inpatient claims data for detecting ACS-NSQIP complications ranged from 0.27 to 0.78; the percentage of false-positives ranged from 48% to 84%. Addition of outpatient claims data improved sensitivity slightly but also greatly increased the percentage of false-positives. Agreement was routinely poor between clinical and claims data for patient-level complications., Conclusions: This analysis demonstrates important differences between ACS-NSQIP and Medicare claims data sets for measuring surgical complications. Poor accuracy potentially makes claims data suboptimal for evaluating surgical complications. These findings have meaningful implications for performance measures currently being considered.

Objective: To summarize the findings of methodological studies on the RAND/University of California Los Angeles (RAND/UCLA) appropriateness method, which was developed to assess if variation in the use of surgical procedures is because of overuse and/or underuse., Study Design and Setting: A MEDLINE literature search was performed. Studies were included if they assessed the reliability or validity of the RAND/UCLA appropriateness method for a surgical procedure or the effect of altering panelist composition or eliminating in-person discussion between rating rounds. Information was abstracted on procedure, study design, and findings., Results: One thousand six hundred one titles were identified, and 37 met the inclusion criteria. The test-retest reliability is good to very good (kappa, 0.64-0.81) for total knee and hip joint replacement, coronary artery bypass grafting (CABG), and carotid endarterectomy (CEA). The interpanel reliability is moderate to very good (kappa, 0.52-0.83) for CABG and hysterectomy. Construct validity has been demonstrated by comparing the appropriateness method with guidelines and/or evidence-based approaches for endoscopy, colonoscopy, CABG, hysterectomy, and CEA. Predictive validity has been studied for cardiac revascularization, in which concordance with appropriateness classification is associated with better clinical outcomes., Conclusion: Our findings support use of the appropriateness method to assess variation in the rates of the procedures studied by identifying overuse and underuse. Further methodological research should be conducted as appropriateness criteria are developed and implemented for a broader range of procedures., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Control charts are used in industry to monitor performance and are being used increasingly in hospitals as a quality improvement tool. The authors' objective was to determine if control charts using surgical site infection (SSI) rates predict changes in outlier status for risk-adjusted SSI rates using data from a surgical registry, the American College of Surgeons National Surgical Quality Improvement Program. Control charts of monthly SSI rates for 100 hospitals were analyzed for indicators of a performance change in 2009 (vs 2008) using standard rules. Hospitals also were classified as having better, worse, or no change in outlier status for risk-adjusted SSI rates in 2009 (vs 2008). There was moderate agreement between these methods (weighted κ = 0.401). Control charts predicted nonworsening performance well (specificity = 92.9%) and identified changes in SSI performance sooner; however, they failed to identify 31.2% of hospitals with worsened outlier status. This study demonstrates that these quality measurement tools have unique strengths and weaknesses and are complementary uses of the same clinical data source.

With increasing focus on improving quality and promoting patient-centered care, ensuring that patients receive appropriate surgical procedures is paramount. The appropriateness method was developed to determine which patients should and should not undergo surgical intervention versus medical therapy. This method combines the best available evidence in the literature with expert opinion to produce explicit guidance for clinicians on the relative risks and benefits of a procedure for specific clinical indications. A coordinated effort to produce appropriateness criteria for surgical oncology could improve the quality of surgical care for patients with cancer if these criteria are integrated into routine clinical practice., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To systematically describe appropriateness criteria (AC) developed in the United States for surgical procedures and to summarize how these criteria have been applied to identify overuse and underuse of procedures in US populations., Data Sources: MEDLINE literature search performed in February 2010 and May 2011., Study Selection: Studies were included if they addressed the appropriateness of a surgical procedure using the RAND-UCLA Appropriateness Method. Non-US studies were excluded., Data Extraction: Information was abstracted on study design, surgical procedure, and reported rates of appropriate use, overuse, and underuse. Identified AC were cross-referenced with lists of common procedures from the Nationwide Inpatient Sample and the State Ambulatory Surgery databases., Data Synthesis: A total of 1601 titles were identified; 39 met the inclusion criteria. Of these, 17 developed AC and 27 applied AC to US populations. Appropriateness criteria have been developed for 16 surgical procedures. Underuse has only been studied for coronary artery bypass graft surgery, and rates range from 24% to 57%. Overuse has been more broadly studied, with rates ranging from 9% to 53% for carotid endarterectomy, 0% to 14% for coronary artery bypass graft, 11% to 24% for upper gastrointestinal tract endoscopy, and 16% to 70% for hysterectomy. Appropriateness criteria exist for 10 of the 25 most common inpatient procedures and 6 of the 15 top ambulatory procedures in the United States. Most studies are more than 5 years old., Conclusions: Most existing AC are outdated, and AC have never been developed for most common surgical procedures. A broad and coordinated effort to develop and maintain AC would be required to implement this tool to address variation in the use of surgical procedures.

Objectives: Key stakeholders agree better data on patients' language are needed to effectively address language-related barriers to timely, highquality healthcare. Our objective was to describe health plan efforts to collect language data from its members, provide language services, and improve the provision of culturally and linguistically appropriate services (CLAS)., Study Design: National surveys in 2003, 2006, and 2008., Methods: Surveys were administered to health plans offering commercial, Medicaid, and/or Medicare Advantage products., Results: 123 health plans responded to the 2008 survey (50% response rate), including 65 commercial (50%), 46 Medicaid (53%), and 12 Medicare plans (44%), representing a total enrollment of 133.8 million Americans. In 2008, 74.0% of health plans collected language data (commercial 60.0%, Medicaid 89.1%, Medicare 91.7%), which is an increase for each plan type since 2003. Health plans used direct and indirect collection methods. Nearly all health plans reported offering language services, the most common being telephonic interpreting, multilingual member materials, and access to bilingual providers. A variety of strategies for improving CLAS were cited by health plans, including improving health plan communication materials, health literacy initiatives for members, and targeted training for providers and staff., Conclusions: Health plans have made substantial progress in the collection of language data and many are offering options for language services. With the rapid growth in Medicaid participation and newly insured individuals anticipated under the Affordable Care Act, health plans may be uniquely positioned to implement and test interventions that aim to improve appropriate utilization of language services by providers and patients.

In 2003 the Institute of Medicine called on health plans to collect data on their members' race and ethnicity as a foundation for improving the quality of care and reducing disparities. We describe the progress made toward collecting these data, the most commonly used data collection methods, and the challenges plans have encountered. We found that from 2003 through 2008, the proportion of plans that collected members' data on race and ethnicity doubled in the commercial market to 60 percent. It increased even more sharply to 94 percent and 83 percent, respectively, for plans covering Medicaid and Medicare Advantage enrollees. However, the scope of data collection varied greatly across plans, and data collection was an organizationwide initiative in a minority of plans. To fulfill the goals of recent legislation, including the Affordable Care Act, health plans will need to expand their efforts. Among other steps, plans and other key stakeholders should agree on uniform race and ethnicity categories, modify information systems to capture these data, and increase members' trust so that self-reported data-the most accurate data on race and ethnicity-can be gathered.

Background: Improving the quality of surgical care depends upon collection of robust data. The American College of Surgeons Case Log System enables surgeons to self-report patient risk factors and outcomes. In contrast, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) uses trained data abstractors to record similar data and uses a strict data collection methodology. The objective of this study was to assess bias in data entry for colorectal cases by comparing data in these 2 registries., Study Design: One year of NSQIP (July 1, 2008 to June 30, 2009) and 7 years of Case Log (2003 to 2010) data were examined. Colorectal cases were identified by current procedural terminology code. The frequencies of comparably defined variables were compared, and mortality models were developed using logistic regression. Observed and expected mortality rates were compared., Results: Rates of most risk factor and outcome variables were significantly higher in NSQIP than those in Case Log. NSQIP had a higher unadjusted mortality rate (4.46% versus 3.69%, p < 0.001); however, the adjusted odds of mortality was significantly higher in Case Log (odds ratio 1.32, p < 0.05). The Case Log model overpredicted mortality in NSQIP by 22%, whereas the NSQIP model underpredicted mortality in Case Log by 12%., Conclusions: Significant differences exist between risk factor and outcome data in NSQIP and Case Log for colorectal procedures. These differences demonstrate the need for standardized data collection methods, as is required by NSQIP, including use of standard definitions, adherence to a follow-up period for outcomes, and use of audits. These measures would improve the validity of using a self-reported database to evaluate and benchmark performance., (Copyright © 2011 American College of Surgeons. All rights reserved.)