Raphael P. Nenner

Laparoscopic and open cholecystectomy in New York State: Mortality, complications, and choice of procedure

BACKGROUND With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.

The Effects of Regionalization on Clinical Outcomes for a High Risk Surgical Procedure: A Study of the Whipple Procedure in New York State

The purpose of this study was to analyze the effects on clinical outcomes of regionalization for a high risk surgical procedure, pancreaticoduodenectomy (the Whipple procedure). Claims data were examined for all Medicare patients undergoing the procedure in New York State for the 4-year period 1991-1994. Outcomes were analyzed for two regional hospitals and for 115 other hospitals that performed the procedure. In-hospi tal mortality and length of stay were significantly less at the two high volume regional hospitals when compared with the remaining low volume hospitals. In-hospital mortality rates at all hospitals generally decreased as the number of procedures increased. The results of this study demonstrate that there is significant value in re gionalization for even relatively lower volume high risk surgical procedures.

Increased cholecystectomy rates among Medicare patients after the introduction of laparoscopic cholecystectomy.

A study was undertaken of Medicare claims coded for cholecystectomy and those coded for laparoscopic cholecystectomy for the four year period 1990–1993 in New York State. During this time period there was a 28.12% increase in total cholecystectomies performed and an increase in the proportion of laparoscopic cholecystectomies from 15.86% to 50.0%. The increase in total cholecystectomies appears to be driven by a dramatic increase in laparoscopic procedures. Possible reasons for this increase include the performance of laparoscopy on patients previously assessed as too risky to undergo the conventional procedure, laparoscopy on mildly symptomatic patients who had previously put off a perceived higher risk open procedure and a possible broadening of indications for gallbladder surgery.The dramatic increase in the numbers of cholecystectomies performed in the early 1990s may be due in part to procedures performed on a large pool of procrastinating mildly symptomatic patients. If this is the case, then these increased rates should decline to baseline levels as soon as this pool of patients is exhausted. However, if surgeons are performing laparoscopy on asymptomatic patients with gallstones, then these rates may well be sustained. Such a broadening of indications for gallbladder surgery is of concern to many and has prompted the issuance of guidelines concerning the treatment of gallstones. Any broadening of indications for gallbladder surgery also has significant implications for health care costs and the use of health care resources.

Trends in Radical Prostatectomy in New York State

The purpose of this study was to examine trends in radical prostatectomy in New York State for the period 1991-1993. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries in New York State for the period 1991-1993. Basic trend data were also analyzed for 1990. Pattern analysis was conducted on the 4,154 procedures performed between 1990-1993. In depth hospital chart review was conducted of the 220 cases of radical prostatectomy performed in pa tients 75 years of age and over between 1991 and 1993 and of a random sample of 263 of 1,266 patients 70-74 years of age. A total of 452 hospital charts were exam ined for a broad range of information, including family history and therapeutic preferences, preoperative work-up, staging, intraoperative and postoperative transfusions, postoperative complications, and mortality. The rate of radical prostatectomy dramatically rose among New York State male Medicare beneficiaries be tween 1990 and 1992 and remained at a high plateau in 1993. Pattern analysis revealed a tripling of the proce dure rate among those 70-74 years of age and a doubling of the rate in those 75 years of age and older. It was also found that a high proportion of radical prostatecto mies in men 70 years of age and older were performed by relatively few hospitals. Although rates of radical prostatectomy rose in New York State during the period under study, these rates were lower than those reported several years earlier in other parts of the country. This may reflect an overall conservative approach to the management of prostate cancer, especially among older men, on the part of New Yorks urologic community. The overall postoperative complication rate was 18.5% and the mortality rate 1.3%. These rates are simi lar to those found in other series. Prostate cancer in older men usually has a protracted course. Radical pros tatectomy in such men is associated with operative risks, and significant immediate and long-term compli cations. In addition, the procedure provides only mar ginal benefit of 10 years because of competing mortality in older men. The results of this study show a need for provider and patient focused educational efforts to reduce the numbers of radical prostatectomies in older men where the benefits are marginal compared to operative risks and significant immediate and long term complications.

Hospital reported complications of laparoscopic cholecystectomy among Medicare and Medicaid patients.

The purpose of this study was to initiate a hospital-based case review of all laparoscopic cholecystectomies performed on Medicare and Medicaid patients in New York State in 1991 where there were one or more complications. Another purpose was to facilitate efforts by hospitals to monitor the performance of laparoscopic cholecystectomy through an educational process of data-sharing.There were 2,940 Medicare and 1,108 Medicaid cholecystectomies in New York State in 1991. Of these, 351 (11.9%) Medicare and 107 (9.7%) Medicaid patients were reported as having complications. The complication rate for Medicare patients was slightly lower than that observed (15.8%) in an epidemiologic study of Medicare patients in New York State who underwent laparoscopic cholecystectomy during the period January 1, 1990–June 30, 1991.Both of these observed rates for Medicare patients are higher than the mean 6.0% complication rate reported for open cholecystectomy in the literature. These increased rates may in part be due to age related risk factors present among Medicare patients. The absence of age related risk factors may also largely account for the lower laparoscopic cholecystectomy complication rate (9.7%) observed among Medicaid patients.The complication rate of 9.7% for Medicaid patients is similar to rates reported in other recent studies. The 11.9% complication rate for Medicare patients is higher than that reported in other recent studies. However, careful patient selection, the absence of age related risk factors, and greater surgical experience may account for the lower complication rates reported in some published series.Overall, the coding of complications was found to be accurate. The coding of laparoscopic cholecystectomy was found to be slightly flawed.Few of the adverse events leading to complications were deemed preventable by the hospitals. Surgeons often dealt with intraoperative problems by converting to a conventional open procedure.Hospitals should continue to monitor their experience with laparoscopic cholecystectomies over time, and should provide educational feedback to their medical staffs regarding these findings.

Impact of an Educational Program on Bilateral Heart Catheterization Practice Patterns

The value and necessity of performing right heart catheterizations for coronary artery disease have been increasingly questioned. Preliminary analyses of the procedure among Medicare and Medicaid patients in New York State revealed significant inter-hospital variations in the frequencies with which such catheterizations were performed. These data suggested that right heart catheterizations (RHC) were being performed routinely. Medicare and Medicaid claims data for bilateral catheterizations were analyzed before and after an educational intervention program involving the states 53 catheterization laboratories. The educational intervention was multifaceted and consisted of disseminating suggested guidelines established with the assistance of the New York State Chapter of the American College of Cardiology, the Committee on Cardiovascular Disease of the Medical Society of the State of New York, and the Cardiac Advisory Council of the New York State Department of Health. Posteducational intervention assessments were made over a 4-year period. The baseline data for 1992 demonstrated that 10 (18.4%) laboratories had performed RHC routinely (70-100%) on Medicare and Medicaid patients undergoing catheterization. In contrast, 34 (64.2%) laboratories performed RHC in less than 20% of their Medicare cases, whereas 39 (73.5%) did so among Medicaid cases. Eighteen (34%) laboratories performed RIHC in less than 10% of Medicare cases. These data indicated that there was significant inter-hospital variation in the frequency with which RHC was performed. Beginning in 1993, ongoing educational meetings and conferences were held with all laboratories, but especially with the 10 that were at the high end of the RHC performance level. As a result of this ongoing intervention, the rate of RHC among Medicare patients fell from 89/100,000 in 1992 to 65/100,000 beneficiaries in 1996. From another perspective, the percentage of catheterized Medicare patients undergoing RHC fell from 30.5% in 1992 to 17.4% in 1996. The decline among the 10 laboratories was even more dramatic; the percentage of catheterized Medicare patients undergoing RHC fell from 89.1% in 1992 to 31.6% in 1996. The parallel drop for Medicaid patients over the same time period was from 92.8 to 32.7%. The results of the study indicate that many previously performed RHC in patients with coronary artery disease were routine and not medically indicated. The dramatic decreases in RHC documented in this study over a 4-year period demonstrate the success of quality improvement efforts jointly undertaken by providers and a peer review organization.

QUALITY OF CARE PROBLEMS AMONG MEDICARE AND MEDICAID PATIENTS

The purpose of this study was to characterize quality of care problems among Medicare and Medicaid inpatients in New York State. The patients selected for this study comprised 1991 and 1992 Medicare and all 1992 Medicaid inpatients in whom quality of care problems with actual or potential adverse effects were found. The patients in this study were drawn from public, proprietary, voluntary and teaching hospitals.A total of 1000 quality of care problems with either actual or potential adverse effects were found in 706 Medicare patients. Two hundred and seventy-five (275) quality of care problems with actual or potential adverse effects were found in 154 Medicaid patients. Premature death occurred in 53 (7.4%) of the 706 Medicare and in 42 (27.2%) of the 154 Medicaid patients. Treatment problems and monitoring failures accounted for the majority of quality of care problems with actual or potential adverse effects for both Medicare (63.0%) and Medicaid (75.7%) patients. Among Medicare patients, the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use were among the leading causes of quality of care problems. Attending physicians were associated with the majority of Medicare quality of care problems while house staff and attending physicians were associated with the majority of those among Medicaid patients.The results of this study indicate that there are several leading causes of quality of care problems among Medicare and Medicaid patients. Treatment problems and monitoring failures together comprise the majority of such problems. Among Medicare patients, it was found that most quality of care problems were associated with the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use. Most quality of care problems among Medicaid patients were associated with these categories as well as with labor and delivery problems, and poor discharge planning.The results of this study reflect the peer-review process in which providers are given an opportunity to respond to physicianreviewer decisions about the presence of actual or potential adverse effects. Such a process, which permits the presentation of additional data and information by providers, produces fewer final adverse outcome determinations than a process uniquely based on chart review.The quality of care problems observed in this study are amenable to focused educational interventions. Such remedial interventions could yield significant improvements in the quality of care for all patients.

Concurrent improvements in ambulatory cardiac catheterization practices following inpatient interventions.

Questions have been increasingly raised about the value of performing right heart catheterization. A preliminary analysis done in 1992 revealed significant interhospital variation in the frequency of the procedure among Medicare Part A and Medicaid patients in New York State, and it also suggested that the procedure was being performed routinely in some hospitals. In 1993, IPRO initiated a cooperative health care quality improvement program involving the states 53 catheterization laboratories. As a result of this educational intervention, the rate of bilateral catheterization among Medicare Part A patients fell from 89/100,000 beneficiaries in 1992 to 65/100,000 in 1996, and the overall percentage of catheterized Medicare patients undergoing bilateral catheterization fell from 30.5% in 1992 to 17.4%. A major question was whether a corresponding decrease had occurred among ambulatory patients (Medicare Part B). To determine the answer, the Medicare Part B database was analyzed for the identical period of time. It was found that the percentage of ambulatory Medicare patients who underwent bilateral catheterization at the 53 laboratories fell from 37.6% in 1992 to 17.0% in 1996, paralleling the decline observed among inpatients. The results of this quality improvement study show that an educational intervention directed at inpatient practice patterns can have a similar impact on outpatient patterns.

IPRO's Health Care Quality Improvement Program.

IPRO is a peer-review organization in New York State that functions under a contract with the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services for assuring quality of care for Medicare patients. In 1993, IPRO initiated its Health Care Quality Improvement Program (HCQIP). The purpose of this program is to develop information on patterns of care and outcomes, to share this with health care providers, and in so doing effect measurable improvements in care and outcomes. In order to achieve improvements in the quality of care, IPRO has initiated a series of cooperative projects which combine pattern analysis and feedback. These cooperative projects cover a broad range of medical care issues and areas. They have demonstrated that IPRO, providers, and physicians can collaborate to establish and implement efforts to achieve the ultimate goal of improved quality of care for Medicare beneficiaries.