How Total Performance Scores of Medicare Value-Based Purchasing Program Hospitals Change Over Time.

BACKGROUND AND PURPOSE: The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type. METHODS: Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types. RESULTS: Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations. CONCLUSION: In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores. IMPLICATIONS: Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.

New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs.

BACKGROUND: New pediatric and vascular surgical fellowship programs decrease resident operative experience in those subspecialties in co-located general surgery programs.After 2 decades of increases, the mean number of endocrine surgery cases performed by general surgery residents nationally has decreased since 2010 to 2011. We hypothesized that new endocrine surgery fellowship programs lead to a decrease in the number of endocrine surgery cases performed by co-located general surgery residents and may be a contributing factor in the recent national decline in endocrine surgery cases performed by general surgery residents. METHODS: Endocrine surgery fellowship programs associated with a single, Accreditation Council of Graduate Medical Education-accredited general surgery program that have completed training of 1 fellow by the 2014-2015 academic year were identified. Endocrine surgery cases performed by general surgery residents who completed co-located general surgery programs from 2002 to 2003 through 2017 to 2018 were recorded. Descriptive statistics are shown as mean ± standard deviation. Statistical significance was calculated using the Mann-Whitney U Test. RESULTS: In the 13 general surgery programs with 5 years of case log data after the matriculation of the first fellow, the mean number of total endocrine surgery cases/resident increased from 47 ± 23 in year 0 to 57 ± 25 in year 5 (z-score = 2.53; P < .05). CONCLUSION: New endocrine surgery fellowship programs do not decrease the endocrine surgery cases performed by general surgery residents and have not contributed to the national decline in endocrine surgery cases by general surgery residents.

The ups and downs of general surgery resident experience in endocrine surgery: Analysis of 30 years of ACGME graduate case logs.

BACKGROUND: The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases. METHODS: American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level. RESULTS: The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P < .001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P < .001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P < .001) but peaked at 23.5 in 2010 to 2011 and have since declined (P < .001). Parathyroid operations more than doubled from 4.2 to 9.7 (P < .001). Adrenal operations increased from 1 to 2.2 (P < .001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P < .001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P < .001). Surgeon Junior endocrine surgery cases increased overall (P < .001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P < .001). CONCLUSION: After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity.

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits.

BACKGROUND: Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training. METHODS: A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods. RESULTS: Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01). CONCLUSIONS AND RELEVANCE: Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

Observations on the Medicare Value-Based Ranking of Hospitals During Fiscal Years 2015 and 2016.

Medicare's Value-Based Purchasing Program (VBPP) compensates hospitals based on value of care provided. VBPP's total performance score (TPS) components data were evaluated by hospital groups: physician-owned surgical hospitals (POSH), Kaiser Hospitals, University HealthSystem Consortium Hospitals, Pioneer Accountable Care Organization Hospitals, US News and World Report Honor Roll Hospitals, and other hospitals. Multilevel random coefficient models estimated mean and significance of TPS differences from fiscal year (FY) 2015 and FY 2016, by hospital type. Overall mean TPS for 2985 hospitals decreased from 41.65 to 40.25. POSH and Kaiser Hospitals had significantly higher TPS in FY 2015 and FY 2016. POSH Patient Experience Domain scores exceeded all other Patient Experience Domain scores. The Efficiency Domain scores of Kaiser greatly exceeded the scores of all groups. Results suggest that POSH and Kaiser Hospitals provide significantly greater value of care with consistency from year to year when compared with other groups studied.

Individual Surgeon's Contribution to Value.

Estimating surgeon-level value in health care remains relatively unexplored. American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2013) were linked with total costs at a single institution. Random intercepts in 3-level random effects logistic regression models predicted 30-day postoperative mortality or morbidity for each surgeon each year. Value was defined as quality (morbidity or mortality) divided by costs for surgeons performing general surgery and vascular procedures. Forty-four surgeons performed 11 965 surgeries. Risk-adjusted costs trended down over time. For all surgeries, mortality value increased by 3.27 per year (95% confidence interval = 2.54-4.01; P < .001) on a 100-point scale, while morbidity value did not change. Of 21 surgeons with data for 5 years or longer, mortality value increased for all surgeons except one. Continuous increase in complication rates from 2008 contributed to decreased morbidity value. Value may assist surgeons in exploring performance opportunities better than morbidity or mortality alone.

Preoperative Gastroesophageal Reflux Disorder Is Associated With Increased Morbidity in Patients Undergoing Abdominal Surgery.

BACKGROUND: In North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. METHOD: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP-targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP-targeted procedure groups, and open versus laparoscopic surgery. RESULTS: Of 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P < 0.001). CONCLUSIONS: Preoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

Long-Term Skills Retention Following a Randomized Prospective Trial on Adaptive Procedural Training.

OBJECTIVE: Cumulative sum (CuSum) is a real-time proficiency-monitoring tool adapted for simulation-based training. This study's objective was to investigate long-term outcomes of a double blinded, randomized control trial conducted with medical students assessing CuSum-guided curriculum against volume-based standards. The trial found a nearly 20% reduction in practice time to reach proficiency using the CuSum curriculum but long-term effects of decreased practice volume on proficiency is unknown. DESIGN: Prior participants completed a survey assessing confidence, exposure, and feedback at 12 to 18 months following trial completion. They underwent retention testing of suturing, intubation, and central venous catheter placement (CVC), which was video-recorded and assessed by an expert evaluator. Baseline characteristics among repeat subjects were compared using chi-squared tests. Retention and initial trial outcome were compared using paired parametric statistical methods. SETTING: The study was conducted at a major tertiary care center and training hospital. PARTICIPANTS: Medical students, which completed the initial randomized control trial were eligible for enrollment. A total of 30/46(65%) responded to the survey, whereas 33/46(72%) completed retention testing. RESULTS: Average scores and decay in procedural tasks over time for suturing, intubation and CVC were 91.6% (-4.7%), 86.1% (-4.1%), and 76.2% (-14.8%), respectively. Compared to the control group, the CuSum group mean difference in retention evaluation scores was -5.6% (p = 0.12). Confidence was not associated with initial or retention testing performance in any procedural task. Higher confidence was associated with additional exposure to the procedural task in suturing and intubation (p = 0.03 and p = 0.02, respectively). For intubation, higher confidence was reported by participants who received positive feedback (p = 0.01), and those assigned to the volume-based training arm (p = 0.03). CONCLUSION: CuSum-guided training was equivalent to conventional training for suturing, intubation, and CVC. These findings importantly suggest medical students can retain competency in invasive surgical tasks with modest decay in proficiency over time regardless of initial training method.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda.

BACKGROUND: The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty. METHODS: Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants' responses. RESULTS: Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45). CONCLUSIONS: General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program.

BACKGROUND: The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. STUDY DESIGN: The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. RESULTS: Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. CONCLUSIONS: The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals.

Using Interdisciplinary Workgroups to Educate Surgery Residents in Systems-Based Practice.

BACKGROUND: Meaningful education of residents in systems-based practice is notoriously challenging, despite its recognition as 1 of the 6 Accreditation Council for Graduate Medical Education core competencies. To address this challenge, surgery residents and other members of the health care team were organized into interdisciplinary workgroups that were tasked with developing solutions to "systems issues" confronted on a daily basis. The project's goals included providing more meaningful, hands-on educational experience for residents in system-based practice, while also generating practical solutions to workflow issues through interprofessional collaboration. PROJECT DESIGN: Project participants included all surgery residents at the University of Virginia in Charlottesville, VA, as well as surgical health care professionals across all disciplines. Participants were organized into workgroups. Over the course of 3 sessions, each of 1-hour, each workgroup identified commonly encountered systems issues, chose 1 issue to address, and determined an implementable solution for this issue. In total, 140 participants were divided among 13 workgroups. PROJECT EXECUTION: Workgroup topics ranged from improving paging etiquette to standardizing interdisciplinary communication. In total, 9 of the 13 proposals have been piloted or fully implemented as standard practice at our institution, either within a single unit or over the entire health system. DISCUSSION: This project demonstrates an innovative approach toward resident education in system-based practice, providing residents with a hands-on experience in problem solving from a systems perspective. These interdisciplinary workgroups generated effective solutions to issues that were meaningful to frontline health care providers. Interdisciplinary collaboration within the workgroups served as a valuable team-building exercise to improve relations between the disciplines. This project can serve as a model for other institutions desiring meaningful education in the Accreditation Council for Graduate Medical Education competency of systems-based practice.

Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism.

BACKGROUND: Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. METHODS: A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. RESULTS: Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. CONCLUSION: With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.

Defining the effects of age and gender on immune response and outcomes to melanoma vaccination: a retrospective analysis of a single-institution clinical trials' experience.

BACKGROUND: The impacts of patient age and gender on immune response (IR) and clinical outcome after cancer vaccines are not known. We hypothesized younger and female patients would have higher IR rates and better survival. METHODS: Patients with resected stage IIB-IV melanoma in three clinical trials (Mel43, Mel44, Mel48) were vaccinated with 12 melanoma-associated peptides restricted by class I MHC. The cumulative incidence rate of CD8(+) T cell responses (direct interferon-gamma ELIspot assay) by week 7 was compared by age and gender. Overall survival (OS) and disease-free survival (DFS) landmark analyses were compared by Kaplan-Meier estimates and in multivariate analyses. RESULTS: T cell responses were evaluated in 327 patients and detected in 50 % of males and 48 % of females, with no difference in IR by gender or menopausal status. Males had trends toward longer DFS (p = 0.12) and OS (p = 0.09). Cumulative incidence of IR was higher in patients <64 years of age versus older patients (p = 0.03). OS and DFS were similar by age group (p > 0.50). In multivariate modeling, younger age was associated with better IR (OR 0.40, p value 0.003), without an impact of age or gender on clinical outcomes. CONCLUSION: These data support the hypothesis that older patients are less likely to develop T cell responses to a cancer vaccine. Nonetheless, significant proportions of older patients mount immune responses with comparable survival outcomes. Thus, these data support including older patients in cancer vaccine trials, but suggest value in stratifying patients by age 64 years.