John Cochran Veterans Affairs Medical Center

St. Louis, MO, United States

John Cochran Veterans Affairs Medical Center

St. Louis, MO, United States

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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 | Hall B.L.,BJC Healthcare
Annals of Surgery | Year: 2015

Objective: To assess statistical reliability of hospital profiling models in ACS NSQIP (American College of Surgeons' National Surgical Quality Improvement Program) Background: The ACS NSQIP January 2013 Semiannual Report provided risk-adjusted hospital quality assessments for 137 models. Methods: Median reliability and percentage of hospitals achieving acceptable reliability were computed for each model. Average median reliability was computed across models with common outcomes. Results: Median reliability varied across the 137 models, from a high of 0.91 for "All Cases Morbidity" to a low of 0.005 for "Procedure-Targeted Total Hip Arthroplasty Surgical Site Infection." Generally, reliability was greatest for models with larger sample sizes and higher outcome event rates. Among "Essentials" models, 72% attained a median reliability of 0.40 or more, and 24% of 0.70 or more. Among "Procedure-Targeted" models, 29% attained a median reliability of 0.40 or more, and 3% of 0.70 or more. Percentage of hospitals achieving an acceptable reliability of 0.40 ranged from 98% for "All Cases Morbidity" to 0% for "Procedure-Targeted Pancreatectomy Mortality." For Essentials models, average median reliability for each outcome, except mortality, was more than 0.40. However, for Procedure-Targeted models the average median was less than 0.40. Conclusions: For a large proportion of ACS NSQIP Essentials models, statistical reliability is adequate for assessing surgical quality and differentiating hospital performance. The Procedure-Targeted program is evolving in terms of statistical reliability, with promising results to date. These results also argue for broader discussions of statistical reliability in performance assessments for the profession. Copyright © 2014 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 9 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.


Ko C.Y.,University of California at Los Angeles | Ko C.Y.,VA Greater Los Angeles Healthcare System | 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.


Hamilton B.H.,Washington University in St. Louis | Ko C.Y.,University of California at Los Angeles | Ko C.Y.,Veterans Affairs Greater Los Angeles Healthcare System | 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.


Frencher Jr. S.K.,University of California at Los Angeles | Steeger J.E.,QCMetrix Inc | Rowell K.S.,QCMetrix Inc | Bartzokis K.,QCMetrix Inc | And 3 more authors.
Journal of the American College of Surgeons | Year: 2010

Background: Data used for evaluating quality of medical care need to be of high reliability to ensure valid quality assessment and benchmarking. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has continually emphasized the collection of highly reliable clinical data through its program infrastructure. Study Design: We provide a detailed description of the various mechanisms used in ACS NSQIP to assure collection of high quality data, including training of data collectors (surgical clinical reviewers) and ongoing audits of data reliability. For the 2005 through 2008 calendar years, inter-rater reliability was calculated overall and for individual variables using percentages of agreement between the data collector and the auditor. Variables with > 5% disagreement are flagged for educational efforts to improve accurate collection. Cohen's kappa was estimated for selected variables from the 2007 audit year. Results: Inter-rater reliability audits show that overall disagreement rates on variables have fallen from 3.15% in 2005 (the first year of public enrollment in ACS NSQIP) to 1.56% in 2008. In addition, disagreement levels for individual variables have continually improved, with 26 individual variables demonstrating > 5% disagreement in 2005, to only 2 such variables in 2008. Estimated kappa values suggest substantial or almost perfect agreement for most variables. Conclusions: The ACS NSQIP has implemented training and audit procedures for its hospital participants that are highly effective in collecting robust data. Audit results show that data have been reliable since the program's inception and that reliability has improved every year. © 2010 American College of Surgeons.


Lawson E.H.,University of California at Los Angeles | Lawson E.H.,VA Greater Los Angeles Healthcare System | Hall B.L.,Washington University in St. Louis | Hall B.L.,John Cochran Veterans Affairs Medical Center | And 7 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.


Porembka M.R.,Washington University in St. Louis | Hall B.L.,Washington University in St. Louis | Hall B.L.,John Cochran Veterans Affairs Medical Center | Hirbe M.,Washington University in St. Louis | Strasberg S.M.,Washington University in St. Louis
Journal of the American College of Surgeons | Year: 2010

Background: To quantify severity of postoperative complications based on the Accordion Severity Grading System, determine the ability of severity grading to enhance National Surgical Quality Improvement Program (NSQIP) data, and develop an aggregate measure of severity of complications (the postoperative morbidity index). Study Design: Forty-three surgical experts rated case vignettes containing postoperative complications on a severity scale. Vignettes were based on the Accordion Severity Grading System derived from the Toronto Severity Grading System. The system was adjusted using the expert severity scale results and applied to 1 year of NSQIP outcomes (1,857 patients, 704 complications) at a large tertiary care center. Results: Experts initially distinguished the 6 grades of severity in a highly significant manner (t-test probabilities all < 0.005), with 1 exception. They rated reoperation and single-system organ failure without reoperation as similar, rather than distinct, in severity. The Accordion System was adjusted to reflect this. Distinction of grades thereafter was highly significant (t-test probabilities all < 0.005). Application to American College of Surgeons NSQIP data provided important novel insights. For example, complications in 6 American College of Surgeons NSQIP categories spanned 4 or more severity grades. Severity-weighted outcomes revealed that quantitatively the greatest burden of outcomes was due to wound infection, shock, and return to the operating room, which is not revealed by unweighted outcomes. Based on this information, an aggregate measure of severity of complications-the postoperative morbidity index-was proposed. Conclusions: Quantitative severity weighting of complications is feasible. Adjustment of American College of Surgeons NSQIP outcomes using this quantitative severity grading system provides uniquely informative representations of relative burdens of morbidities. © 2010 American College of Surgeons.


Kanwal F.,John Cochran Veterans Affairs Medical Center | Schnitzler M.S.,Saint Louis University | Bacon B.R.,Saint Louis University | Hoang T.,Veterans Affairs Greater Los Angeles Medical Center | And 2 more authors.
Annals of Internal Medicine | Year: 2010

Background: Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown. Objective: To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care. Design: Retrospective cohort study. Setting: Nationwide U.S. health insurance company research database. Participants: 10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator. Measurements: Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative. Results: Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]). Limitations: The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care - and not the care itself - is suboptimum. Conclusion: Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care. Primary Funding Source: Saint Louis University Liver Center.


Kiefer S.M.,Saint Louis University | Kiefer S.M.,John Cochran Veterans Affairs Medical Center | Robbins L.,Saint Louis University | Robbins L.,John Cochran Veterans Affairs Medical Center | And 2 more authors.
PLoS ONE | Year: 2012

During kidney development, canonical Wnt signaling activates differentiation, while the transcription factor Six2 maintains the progenitor pool. These opposing signals help to regulate nephron formation and ensure the full complement of nephrons are formed. Since these two factors control differing fates in kidney mesenchyme, we hypothesized that overexpression of Wnt9b in Six2-expressing cells would disrupt kidney formation and may alter cell differentiation decisions in other tissues. We created a transgenic mouse that conditionally expressed the canonical Wnt ligand in the developing kidney, Wnt9b. The transgene is activated by cre recombinase and expresses GFP. We first tested its biological activity using Hoxb7-cre and found that transgenic Wnt9b was capable of inducing differentiation genes and of rescuing kidney development in Wnt9b-/- homozygous deficient mice. In contrast, expression of Wnt9b in cells using Six2-cre caused gastrointestinal distress and severe renal failure in adult mice. Transgenic kidneys had numerous cystic tubules and elevated creatinine values (0.652±0.044) compared to wild-type mice (0.119±0.002). These animals also exhibited a malformed pyloric sphincter, duodenogastric reflux, and a transformation of the distal stomach into proximal fate. The gene expression changes observed for the Wnt9b:EGFP transgene were compared to a stabilized β-catenin allele to determine that Wnt9b is activating the canonical Wnt pathway in the tissues analyzed. These results demonstrate that expression of Wnt9b in Six2-positive cells disrupts cell fate decisions in the kidney and the gastrointestinal tract.

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