Andrew J. Mullard

Hospital and Payer Costs Associated With Surgical Complications

IMPORTANCE Increased costs of surgical complications have been borne mostly by third-party payers. However, numerous policy changes aimed at incentivizing high-quality care shift more of this burden to hospitals. The potential effect of these policies on hospitals and payers is poorly understood. OBJECTIVE To evaluate costs associated with surgical quality and the relative financial burden on hospitals and payers. DESIGN, SETTING, AND PARTICIPANTS We performed an observational study merging complication data from the Michigan Surgical Quality Collaborative and internal cost accounting data from the University of Michigan Health System from January 2, 2008, through April 16, 2015; the merged files from these data were created between June 5, 2015, and July 22, 2015. A total of 5120 episodes of surgical care for 24 surgical procedure groups (17 general surgical, 6 vascular, and 1 gynecologic) were examined. We report unadjusted and log-transformed risk-adjusted costs. MAIN OUTCOMES AND MEASURES We compared hospital costs, third-party reimbursement (ie, payer costs), and hospital profit margin for cases with and without complications. RESULTS The mean (SD) age of the 5120 patients was 56.0 (16.4) years, and 2883 (56.3) were female. The overall complication rate was 14.5% (744 of 5120) for all procedures, 14.7% (580 of 3956) for general surgery, 15.5% (128 of 828) for vascular surgery, and 10.7% (36 of 336) for gynecologic surgery. For all studied procedures, mean hospital costs were

Complication Rates of Ostomy Surgery Are High and Vary Significantly Between Hospitals

19 626 (119%) higher for patients with complications (

Improving the Care of Elderly Adults Undergoing Surgery in Michigan

36 060) compared with those without complications (

Optimizing value of colon surgery in Michigan

16 434). Mean third-party reimbursement was

Hospital variation in outcomes following appendectomy in a regional quality improvement program

18 497 (106%) higher for patients with complications (

Hospital Analgesia Practices and Patient-reported Pain After Colorectal Resection

35 870) compared with those without complications (

Complications after discharge predict readmission after colorectal surgery

17 373). Consequently, with risk adjustment, overall profit margin decreased from 5.8% for patients without complications to 0.1% for patients with complications. CONCLUSIONS AND RELEVANCE Hospitals and third-party payers experience increased costs with surgical complications, with hospitals experiencing a reduction in profit margin. Both hospitals and payers appear to currently have financial incentives to promote surgical quality improvement.

Evaluating Surgeon Scorecards

BACKGROUND: Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. OBJECTIVE: The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement. DESIGN: This was a retrospective cohort study. SETTINGS: The study took place within the 34-hospital Michigan Surgical Quality Collaborative. PATIENTS: Patients included were those undergoing ostomy creation surgery between 2006 and 2011. MAIN OUTCOME MEASURES: We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type). RESULTS: A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4–43.9) to 60.8% (95% CI, 48.9–72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. LIMITATIONS: This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes. CONCLUSIONS: Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery

To determine whether failure to rescue, as a driver of mortality, can be used to identify which hospitals attenuate the specific risks inherent to elderly adults undergoing surgery.

Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database

Objective: To assess the value of bundling perioperative care measures in colon surgery. Background: Surgical site infections (SSI) in colectomy are associated with increased morbidity and cost. Perioperative care bundling has been designed to improve processes of care surrounding colectomy operations. Methods: Retrospective cohort study performed by the Michigan Surgical Quality Collaborative (MSQC) of patients who underwent elective colon surgery from 2012 to 2015. We identified 3,387 patients in the MSQC database who underwent colon surgery. Of these cases, 332 had associated episodic cost data. Results: High compliance (3–6 bundle elements) and low compliance (0–2 bundle elements) had a risk-adjusted SSI rate of 8.2% (95% confidence interval, CI, 7.2–9.2%) and 16.0% (95% CI, 12.9–19.1%), respectively (P < 0.01). When compared with low compliance, the high compliance group had an absolute risk reduction of 3.6% (P < 0.01), 2.9% (P < 0.01) and 1.3% (P < 0.01) for SSI rates in superficial space, deep space, and organ space, respectively. Low compliance had an average episodic cost of