Andrew A. Gonzalez

Understanding the Volume-Outcome Effect in Cardiovascular Surgery: The Role of Failure to Rescue

IMPORTANCE To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. OBJECTIVE To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications. DESIGN, SETTING, AND PARTICIPANTS We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile. EXPOSURE Hospital procedural volume. MAIN OUTCOMES AND MEASURES Hospital rates of risk-adjusted mortality, major complications, and failure to rescue. RESULTS For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred. CONCLUSIONS AND RELEVANCE High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.

Using same-hospital readmission rates to estimate all-hospital readmission rates.

BACKGROUND Since October of 2012, Medicares Hospital Readmissions Reduction Program has fined 2,200 hospitals a total of

Mortality among Older Adults before Versus after Hospital Transition to Intensivist Staffing

500 million. Although the program penalizes readmission to any hospital, many institutions can only track readmissions to their own hospitals. We sought to determine the extent to which same-hospital readmission rates can be used to estimate all-hospital readmission rates after major surgery. STUDY DESIGN We evaluated 3,940 hospitals treating 741,656 Medicare fee-for-service beneficiaries undergoing CABG, hip fracture repair, or colectomy between 2006 and 2008. We used hierarchical logistic regression to calculate risk- and reliability-adjusted rates of 30-day readmission to the same hospital and to any hospital. We next evaluated the correlation between same-hospital and all-hospital rates. To analyze the impact on hospital profiling, we compared rankings based on same-hospital rates with those based on all-hospital rates. RESULTS The mean risk- and reliability-adjusted all-hospital readmission rate was 13.2% (SD 1.5%) and mean same-hospital readmission rate was 8.4% (SD 1.1%). Depending on the operation, between 57% (colectomy) and 63% (CABG) of hospitals were reclassified when profiling was based on same-hospital readmission rates instead of on all-hospital readmission rates. This was particularly pronounced in the middle 3 quintiles, where 66% to 73% of hospitals were reclassified. CONCLUSIONS In evaluating hospital profiling under Medicares Hospital Readmissions Reduction Program, same-hospital rates provide unstable estimates of all-hospital readmission rates. To better anticipate penalties, hospitals require novel approaches for accurately tracking the totality of their postoperative readmissions.

Medicare's Hospital Readmissions Reduction Program in surgery may disproportionately affect minority-serving hospitals

Background:A large body of research suggests that hospitals with intensive care units staffed by board-certified intensivists have lower mortality rates than those that do not. Objective:To determine whether hospitals can reduce their mortality by adopting an intensivist staffing model. Design:Retrospective, longitudinal study using 2003–2010 Medicare data and the Leapfrog Group Hospital surveys. Setting and Patients:In total, 2,916,801 Medicare patients at 488 US hospitals. Measurements:We studied 30-day and in-hospital mortality among patients with several common medical and surgical conditions. We first compared risk-adjusted mortality rates of 3 groups of hospitals: those that were intensivist staffed throughout this time period, those that were not intensivist staffed, and those that transitioned to intensivist staffing somewhere during the period. We then examined rates of mortality improvement within each of the 3 groups and used difference-in-differences techniques to assess the independent effect of intensivist staffing among the subset of hospitals that transitioned. Results:Hospitals with intensivist staffing at the beginning of our study period had lower mortality rates than those without. However, hospitals that adopted intensivist staffing during the study period did not substantially improve their mortality rates. In our difference-in-differences analysis, there was no significant independent improvement in mortality after transitioning to intensivist staffing either overall [relative risk (RR), 0.96; 95% confidence interval (CI), 0.90–1.02] or in the medical (RR, 0.95; 95% CI, 0.89–1.02) or surgical populations (RR, 0.97; 95% CI, 0.84–1.10). Limitations:Risk adjustment was based on administrative data. Categorization of exposure was by survey response at the hospital level. Conclusions:Adoption of an intensivist staffing model was not associated with improved mortality in Medicare beneficiaries. These findings suggest that the lower mortality rates previously observed at hospitals with intensivist staffing may be attributable to other factors.