Andrew M. Ibrahim

Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery

Importance Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known. Objective To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort. Design, Settings, and Participants This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band–related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed. Main Outcomes and Measures Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations. Results Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid

Association of Hospital Critical Access Status With Surgical Outcomes and Expenditures Among Medicare Beneficiaries

470 million for laparoscopic gastric band associated procedures, of which

Variation in Outcomes at Bariatric Surgery Centers of Excellence

224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device. Conclusions and Relevance Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.

Impact of the Hospital Readmission Reduction Program on Surgical Readmissions Among Medicare Beneficiaries

IMPORTANCE Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures. OBJECTIVE To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. EXPOSURES Undergoing surgical procedures at critical access vs non-critical access hospitals. MAIN OUTCOMES AND MEASURES Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization. RESULTS Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P < .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals (

Novel Uses of Video to Accelerate the Surgical Learning Curve.

14,450 vs

Monitoring Medical Devices: Missed Warning Signs Within Existing Data

15,845; difference, -

Hospital Quality and Medicare Expenditures for Bariatric Surgery in the United States

1395, P < .001). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.

Emergency Surgery for Medicare Beneficiaries Admitted to Critical Access Hospitals

Importance In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown. Objective To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers. Design, Setting, and Participants This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017. Main Outcomes and Measures Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume. Results In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Conclusions and Relevance Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.

Pretherapy neutrophil to lymphocyte ratio and platelet to lymphocyte ratio do not predict survival in resectable pancreatic cancer

Objective: To understand the impact of the Hospital Readmission Reduction Program on both future targeted and nontargeted surgical procedures. Background: The Hospital Readmission Reduction Program, established under the Affordable Care Act in March of 2010, placed financial penalties on hospitals with higher than expected rates of readmission beginning in 2012 for targeted medical conditions. Multiple studies have suggested a “spill-over” effect into other conditions, but the extent of that effect for specific surgical procedures is unknown. Methods: A retrospective review 5,122,240 Medicare beneficiaries who underwent future targeted procedures (total hip replacement, total knee replacements) or nontargeted procedures (colectomy, lung resection, abdominal aortic aneurysm repair, coronary artery bypass graft, aortic valve replacement, mitral valve repair) using an interrupted time series model to assess the rates of readmission before the Hospital Readmission Reduction Program was announced (2008–2010), whereas the program was being implemented (2010–2012) and after penalties were initiated (2012–2014). We also explored if the change in readmission rates were correlated with changes in index length of stay, use of observation status, or discharge to a skilled nursing facility. Results: From 2008 to 2014 rates of readmission declined for both target conditions (6.8%–4.8%; slope change −0.07 to −0.10, P < 0.001) and nontarget conditions (17.1%–13.4%; slope change −0.04 to −0.11, P < 0.001). The rate of reduction was most prominent after announcement of the program between 2010 and 2012 for both targeted and nontargeted conditions. During the same time period, mean hospital length of stay decreased; nontargeted conditions (10.4–8.4 days) and targeted conditions (3.6–2.8 days). There was no correlation between hospital reduction in readmissions and use of observation-only admissions (Pearson correlation coefficient = 0.01) or discharge to a skilled nursing facility (Pearson correlation coefficient = 0.05). Conclusions: Trends in readmissions after inpatient surgery are consistent with hospitals responding to financial incentives announced in the Hospital Readmission Reduction Program. There appears to be both an anticipatory effect (future targeted procedures reducing readmission before payments implemented) and a spillover effect (nontargeted procedures also reducing readmissions).

Surgeon Experience and Medicare Expenditures for Laparoscopic Compared to Open Colectomy

Surgeons are under enormous pressure to continually improve and learn new surgical skills. Novel uses of surgical video in the preoperative, intraoperative, and postoperative setting are emerging to accelerate the learning curve of surgical skill and minimize harm to patients. In the preoperative setting, social media outlets provide a valuable platform for surgeons to collaborate and plan for difficult operative cases. Live streaming of video has allowed for intraoperative telementoring. Finally, postoperative use of video has provided structure for peer coaching to evaluate and improve surgical skill. Applying these approaches into practice is becoming easier as most of our surgical platforms (e.g., laparoscopic, and endoscopy) now have video recording technology built in and video editing software has become more user friendly. Future applications of video technology are being developed, including possible integration into accreditation and board certification.