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Ko C.Y.,University of California at Los Angeles | Hall B.L.,Washington University in St. Louis | Hall B.L.,John Cochran Veterans Affairs Medical Center
Annals of Surgery | Year: 2016

Background: The American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) surgical quality feedback models are recalibrated every 6 months, and each hospital is given risk-adjusted, hierarchical model, odds ratios that permit comparison to an estimated average NSQIP hospital at a particular point in time. This approach is appropriate for "relative" benchmarking, and for targeting quality improvement efforts, but does not permit evaluation of hospital or program-wide changes in quality over time. We report on long-term improvement in surgical outcomes associated with participation in ACS NSQIP. Study Design: ACS NSQIP data (2006-2013) were used to create prediction models for mortality, morbidity (any of several distinct adverse outcomes), and surgical site infection (SSI). For each model, for each hospital, and for year of first participation (hospital cohort), hierarchical model observed/expected (O/E) ratios were computed. The primary performance metric was the within-hospital trend in logged O/E ratios over time (slope) for mortality, morbidity, and SSI. Results: Hospital-averaged log O/E ratio slopes were generally negative, indicating improving performance over time. For all hospitals, 62%, 70%, and 65% of hospitals had negative slopes for mortality, morbidity, and any SSI, respectively. For hospitals currently in the program for at least 3 years, 69%, 79%, and 71% showed improvement in mortality, morbidity, and SSI, respectively. For these hospitals, we estimate 0.8%, 3.1%, and 2.6% annual reductions (with respect to prior year's rates) for mortality, morbidity, and SSI, respectively. Conclusions: Participation in ACS NSQIP is associated with reductions in adverse events after surgery. The magnitude of quality improvement increases with time in the program. © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Merkow R.P.,Northwestern University | Merkow R.P.,University of Chicago | Ju M.H.,Northwestern University | Chung J.W.,Northwestern University | And 7 more authors.
JAMA - Journal of the American Medical Association | Year: 2015

IMPORTANCE: Financial penalties for readmission have been expanded beyond medical conditions to include surgical procedures. Hospitals are working to reduce readmissions; however, little is known about the reasons for surgical readmission. OBJECTIVE: To characterize the reasons, timing, and factors associated with unplanned postoperative readmissions. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing surgery at one of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, had clinically abstracted information examined. Readmission rates and reasons (ascertained by clinical data abstractors at each hospital) were assessed for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass. MAIN OUTCOMES AND MEASURES: Unplanned 30-day readmission and reason for readmission. RESULTS: The unplanned readmission rate for the 498 875 operations was 5.7%. For the individual procedures, the readmission rate ranged from 3.8% for hysterectomy to 14.9% for lower extremity vascular bypass. The most common reason for unplanned readmission was surgical site infection (SSI) overall (19.5%) and also after colectomy or proctectomy (25.8%), ventral hernia repair (26.5%), hysterectomy (28.8%), arthroplasty (18.8%), and lower extremity vascular bypass (36.4%). Obstruction or ileus was the most common reason for readmission after bariatric surgery (24.5%) and the second most common reason overall (10.3%), after colectomy or proctectomy (18.1%), ventral hernia repair (16.7%), and hysterectomy (13.4%). Only 2.3%of patients were readmitted for the same complication they had experienced during their index hospitalization. Only 3.3%of patients readmitted for SSIs had experienced an SSI during their index hospitalization. There was no time pattern for readmission, and early (≤7 days postdischarge) and late (>7 days postdischarge) readmissions were associated with the same 3 most common reasons: SSI, ileus or obstruction, and bleeding. Patient comorbidities, index surgical admission complications, non-home discharge (hazard ratio [HR], 1.40 [95%CI, 1.35-1.46]), teaching hospital status (HR, 1.14 [95%CI 1.07-1.21]), and higher surgical volume (HR, 1.15 [95%CI, 1.07-1.25]) were associated with a higher risk of hospital readmission. CONCLUSIONS AND RELEVANCE: Readmissions after surgery were associated with new postdischarge complications related to the procedure and not exacerbation of prior index hospitalization complications, suggesting that readmissions after surgery are a measure of postdischarge complications. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission. Copyright 2015 American Medical Association. All rights reserved.


Hamilton B.H.,Washington University in St. Louis | Ko C.Y.,University of California at Los Angeles | Hall B.L.,Washington University in St. Louis | Hall B.L.,John Cochran Veterans Affairs Medical Center
Journal of the American College of Surgeons | Year: 2010

Background: Studying risk-adjusted outcomes in health care relies on statistical approaches to handling missing data. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides risk-adjusted assessments of surgical programs, traditionally imputing certain missing data points using a single round of multivariable imputation. Such imputation assumes that data are missing at random-without systematic bias-and does not incorporate estimation uncertainty. Alternative approaches, including using multiple imputation to incorporate uncertainty or using an indicator of missingness, can enhance robustness of evaluations. Study Design: One year of de-identified data from the ACS NSQIP, representing 117 institutions and 106,113 patients, was analyzed. Using albumin variables as the missing data modeled, several imputation/adjustment models were compared, including the traditional NSQIP imputation, a new single imputation, a multiple imputation, and use of a missing indicator. Results: Coefficients for albumin values changed under new single imputation and multiple imputation approaches. Multiple imputation resulted in increased standard errors, as expected. An indicator of missingness was highly explanatory, disproving the missing-at-random assumption. The effects of changes in approach differed for different outcomes, such as mortality and morbidity, and effects were greatest in smaller datasets. However, ultimate changes in patient risk assessment and institutional assessment were minimal. Conclusions: Newer statistical approaches to modeling missing (albumin) values result in noticeable statistical distinctions, including improved incorporation of imputation uncertainty. In addition, the missing-at-random assumption is incorrect for albumin. Despite these findings, effects on institutional assessments are small. Although effects can be most important with smaller data-sets, the current approach to imputing missing values in the ACS NSQIP appears reasonably robust.


Lawson E.H.,University of California at Los Angeles | Hall B.L.,Washington University in St. Louis | Hall B.L.,John Cochran Veterans Affairs Medical Center | Louie R.,University of California at Los Angeles | And 5 more authors.
Annals of Surgery | Year: 2013

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. Copyright © 2013 by Lippincott Williams and Wilkins.


Allen C.T.,University of Washington | Law J.H.,University of Washington | Dunn G.P.,Harvard University | Uppaluri R.,University of Washington | Uppaluri R.,John Cochran Veterans Affairs Medical Center
Head and Neck | Year: 2013

The purpose of this review was to provide biological concepts of head and neck cancer metastasis. To attain this goal, we analyzed peer-reviewed articles related to head and neck cancer metastasis obtained though PubMed and archived articles. Articles related to the biologic principles of head and neck cancer metastasis were reviewed and summarized. As locoregional control has improved for patients with head and neck cancer, rates of distant metastasis have not decreased. As patients live longer, many will die of complications related to the development of disease at sites below the clavicles. Emerging evidence now suggests a more complicated framework of metastatic behavior for head and neck cancer. Here, we review the role of regional lymph nodes in containing advanced head and neck cancer, evidence for active as opposed to passive tumor cell metastasis, and clinical implications these concepts have on both treatment of head and neck cancer and future research. © 2012 Wiley Periodicals, Inc.

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