Including socioeconomic status reduces readmission penalties to safety-net hospitals.

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) financially penalizes "excessive" postoperative readmissions. Concerned with creating a double standard for institutions treating a high percentage of economically vulnerable patients, Medicare elected to exclude socioeconomic status (SES) from its risk-adjustment model. However, recent evidence suggests that safety-net hospitals (SNHs) caring for many low-SES patients are disproportionately penalized under the HRRP. We sought to simulate the impact of including SES-sensitive models on HRRP penalties for hospitals performing lower extremity revascularization (LER). METHODS: This is a retrospective, cross-sectional analysis of national data on Medicare patients undergoing open or endovascular LER procedures between 2007 and 2009. We used hierarchical logistic regression to generate hospital risk-standardized 30-day readmission rates under Medicare's current model (adjusting for age, sex, comorbidities, and procedure type) compared with models that also adjust for SES. We estimated the likelihood of a penalty and penalty size for SNHs compared with non-SNHs under the current Medicare model and these SES-sensitive models. RESULTS: Our study population comprised 1708 hospitals performing 284,724 LER operations with an overall unadjusted readmission rate of 14.4% (standard deviation: 5.3%). Compared with the Centers for Medicare and Medicaid Services model, adjusting for SES would not change the proportion of SNHs penalized for excess readmissions (55.1% vs 53.4%, P = .101) but would reduce penalty amounts for 38% of SNHs compared with only 17% of non-SNHs, P < .001. CONCLUSIONS: For LER, changing national Medicare policy to including SES in readmission risk-adjustment models would reduce penalty amounts to SNHs, especially for those that are also teaching institutions. Making further strides toward reducing the national disparity between SNHs and non-SHNs on readmissions, performance measures require strategies beyond simply altering the risk-adjustment model to include SES.

Predictors of prolonged length of stay after elective carotid revascularization.

OBJECTIVE: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS: Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Zone I Balloon Occlusion Time Affects Spinal Cord Injury in the Nonhuman Primate Model.

OBJECTIVES: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model. SUMMARY BACKGROUND DATA: Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined. METHODS: Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals. RESULTS: Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033). CONCLUSIONS: REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes.

Emergency Department Utilization and Readmissions Following Major Surgery: A Retrospective Study of Medicare Data.

BACKGROUND: Reliable strategies for reducing postoperative readmissions remain elusive. As the emergency department (ED) is a frequent source of post-operative admissions, we investigated whether hospitals with high readmission rates also have high rates of post-discharge ED visits and high rates of readmission once an ED visit occurs. METHODS: We conducted a retrospective analysis of 1,947,621 Medicare beneficiaries undergoing 1 of 5 common procedures in 2,894 hospitals between 2008 and 2011. We stratified hospitals into quintiles based on risk-standardized, 30-day post-discharge readmission rates (RSRR) and then compared rates of post-discharge ED visits, proportion readmitted from the ED, and readmissions within 7 days of ED discharge across these quintiles. RESULTS: RSRR varied widely across extremes of hospital quintiles (3.9% to 17.5%). Hospitals with either very low or very high RSRR had modest differences in rates of ED visits (12.4% versus 14.6%). In contrast, the proportion readmitted from the ED was nearly 3 times greater in Hospitals with very high RSRR compared with those with very low RSRR (12% versus 32.2%). These findings were consistent across all procedures. Importantly, hospitals with a low proportion readmitted from the ED did not exhibit an increased rate of readmission within 7 days of ED discharge. CONCLUSIONS: Although hospitals experience similar rates of ED visits following major surgery, some EDs and their affiliated surgeons and health system may deliver care preventing readmissions without an increased short-term risk of readmission following ED discharge. Reducing 30-day readmissions requires greater attention to the coordination of care delivered in the ED.

Examining variation in Medicare payments and drivers of cost for carotid endarterectomy.

BACKGROUND: There is a growing interest in providing high quality and low-cost care to Americans. A pursuit exists to measure not only how well hospitals are performing but also at what cost. We examined the variation in costs associated with carotid endarterectomy (CEA), to determine which components contribute to the variation and what drives increased payments. MATERIALS AND METHODS: Patients undergoing CEA between 2009 and 2012 were identified in the Medicare provider and analysis review database. Hospital quintiles of cost were generated and variation examined. Multivariable logistic regression was performed to identify independent predictors of high-payment hospitals for both asymptomatic and symptomatic patients undergoing CEA. RESULTS: A total of 264,018 CEAs were performed between 2009 and 2012; 250,317 were performed in asymptomatic patients in 2302 hospitals and 13,701 in symptomatic patients in 1851 hospitals. Higher payment hospitals had a higher percentage of nonwhite patients and comorbidity burden. The largest contributors to variation in overall payments were diagnosis-related groups, postdischarge, and readmission payments. After accounting for clustering at the hospital level, independent predictors of high-payment hospitals for all patients were postoperative stroke, length of stay, and readmission ,whereas in the symptomatic group, additional drivers included yearly volume and serious complications. CONCLUSIONS: CEA Medicare payments vary nationwide with diagnosis-related group, readmission, and postdischarge payments being the largest contributors to overall payment variation. In addition, stroke, length of stay, and readmission were the only independent predictors of high payment for all patients undergoing CEA.

A National Study Evaluating Hospital Volume and Inpatient Mortality after Open Abdominal Aortic Aneurysm Repair in Vulnerable Populations.

BACKGROUND: There is a large body of evidence documenting better outcomes for abdominal aortic aneurysm (AAA) repairs performed in high-volume centers. However, it remains unknown if the strength of this volume-outcome relationship is moderated by race or socioeconomic status (SES). METHODS: This is a cross-sectional retrospective cohort study evaluating 60,618 Medicare fee-for-service beneficiaries undergoing open AAA repair across 1,649 hospitals between 2005 and 2009. We selected, a priori, black race and low SES as vulnerable populations based on previous reports showing each is independently associated with higher mortality. Next, we divided hospitals into quintiles of procedural volume and used logistic regression to compare risk-adjusted rates of inpatient mortality across volume quintiles for the overall study population and separately by race (black versus nonblack) and SES (low, middle, and high). RESULTS: Overall, patients treated in the lowest-volume hospitals (LVHs) had higher risk-adjusted inpatient mortality rates than patients treated in the highest-volume hospitals (HVHs) (15.3% vs. 10.6%, P < 0.001). Higher mortality was associated with black versus nonblack race (12.9% vs. 11.7%, P < 0.001) and low SES versus high SES (12.2% vs. 11.6% P < 0.001). While nonblack patients treated in LVHs had higher odds of mortality (versus HVHs, adjusted odds ratio (aOR) 1.83 [1.59-2.11]), this volume-outcome effect was greater for black patients (aOR 2.60 [1.63-4.16]). In contrast, high and low SES patients experienced similar differences in mortality when treated in LVHs (aOR 1.79 [1.49-2.12]; aOR 1.72 [1.28-2.30], respectively). CONCLUSIONS: While a volume-outcome effect was observed in all patients, black patients appeared to derive a disproportionate benefit from undergoing open AAA repair in HVHs. The mechanism underlying these disparate outcomes remains unclear but warrants further evaluation of contributing hospital and patient factors.

Hospital Ownership of a Postacute Care Facility Influences Discharge Destinations After Emergent Surgery.

OBJECTIVE: The aim of the study was to identify hospital characteristics associated with variation in patient disposition after emergent surgery. SUMMARY BACKGROUND DATA: Colon resections in elderly patients are often done in emergent settings. Although these operations are known to be riskier, there are limited data regarding postoperative discharge destination. METHODS: We evaluated Medicare beneficiaries who underwent emergent colectomy between 2008 and 2010. Using hierarchical logistic regression, we estimated patient and hospital-level risk-adjusted rates of nonhome discharges. Hospitals were stratified into quintiles based on their nonhome discharge rates. Generalized linear models were used to identify hospital structural characteristics associated with nonhome discharges (comparing discharge to skilled nursing facilities vs home with/without home health services). RESULTS: Of the 122,604 patients surviving to discharge after emergent colectomy at 3012 hospitals, 46.7% were discharged to a nonhome destination. There was a wide variation in risk and reliability-adjusted nonhome discharge rates across hospitals (15% to 80%). Patients at hospitals in the highest quintile of nonhome discharge rates were more likely to have longer hospitalizations (15.1 vs 13.2; P < 0.001) and more complications (43.2% vs 34%; P < 0.001). On multivariable analysis, only hospital ownership of a skilled nursing facility (P < 0.001), teaching status (P = 0.025), and low nurse-to-patient ratios (P = 0.002) were associated with nonhome discharges. CONCLUSIONS: Nearly half of Medicare beneficiaries are discharged to a nonhome destination after emergent colectomy. Hospital ownership of a skilled nursing facility and low nurse-to-patient ratios are highly associated with nonhome discharges. This may signify the underlying financial incentives to preferentially utilize postacute care facilities under the traditional fee-for-service payment model.

Mortality Among Older Adults Before Versus After Hospital Transition to Intensivist Staffing.

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.

Indication for Lower Extremity Revascularization and Hospital Profiling of Readmissions.

BACKGROUND: Surgical readmissions are common, costly, and the focus of national quality improvement efforts. Given the relatively high readmission rates among vascular patients, pay-for-performance initiatives such as Medicare's Hospital Readmissions Reduction Program (HRRP) have targeted vascular surgery for increased scrutiny in the near future. Yet, the extent to which institutional case mix influences hospital profiling remains unexplored. We sought to evaluate whether higher readmission rates in vascular surgery are a reflection of worse performance or of treating sicker patients. METHODS: This retrospective observational cohort study of the national Medicare population includes 479,047 beneficiaries undergoing lower extremity revascularization (LER) in 1,701 hospitals from 2005 to 2009. We employed hierarchical logistic regression to mimic Center for Medicare and Medicaid Services methodology accounting for age, gender, preexisting comorbidities, and differences in hospital operative volume. We estimated 30-day risk-standardized readmission rates (RSRR) for each hospital when including (1) all LER patients; (2) claudicants; or (3) high-risk patients (rest pain, ulceration, or tissue loss). We stratified hospitals into quintiles based on overall RSRR for all LERs and examined differences in RSRR for claudicants and high-risk patients between and within quintiles. Next, we evaluated differences in case mix (the proportion of claudicants and high-risk patients treated) across quintiles. Finally, we simulated differences in the receipt of penalties before and after adjusting for hospital case mix. RESULTS: Readmission rates varied widely by indication: 7.3% (claudicants) vs. 19.5% (high risk). Even after adjusting for patient demographics, length of stay, and discharge destination, high-risk patients were significantly more likely to be readmitted (odds ratio 1.76, 95% confidence interval 1.71-1.81). The Best hospitals (top quintile) under the HRRP treated a much lower proportion of high-risk patients compared with the Worst hospitals (bottom quintile) (20% vs. 56%, P < 0.001). In the absence of case-mix adjustment, we observed a stepwise increase in the proportion of hospitals penalized as the proportion of high-risk patients treated increased (35-60%, P < 0.001). However, after case-mix adjustment, there were no differences between quintiles in the proportion of hospitalized penalized (50-46%, P = 0.30). CONCLUSION: Our findings suggest that the differences in readmission rates following LER are largely driven by hospital case mix rather than true differences in quality.

Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals.

OBJECTIVE: To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals. BACKGROUND: The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown. METHODS: We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles. RESULTS: Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million). CONCLUSIONS: Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

Time-to-readmission and Mortality After High-risk Surgery.

OBJECTIVES: To determine if mortality varies by time-to-readmission (TTR). BACKGROUND: Although readmissions reduction is a national health care priority, little progress has been made toward understanding why only some readmissions lead to adverse outcomes. METHODS: In this retrospective cross-sectional cohort analysis, we used 2005-2009 Medicare data on beneficiaries undergoing colectomy, lung resection, or coronary artery bypass grafting (n = 1,033,255) to created 5 TTR groups: no 30-day readmission (n = 897,510), less than 6 days (n = 44,361), 6 to 10 days (n = 31,018), 11 to 15 days (n = 20,797), 16 to 20 days (n = 15,483), or more than 21 days (n = 24,086). Our analyses evaluated TTR groups for differences in risk-adjusted mortality (30, 60, and 90 days) and complications during the index admission. RESULTS: Increasing TTR was associated with a stepwise decline in mortality. For example, 90-day mortality rates in patients readmitted between 1 and 5 days, 6 and 10 days, and 11 and 15 days were 12.6%, 11.4%, and 10.4%, respectively (P < 0.001). Compared to nonreadmitted patients, the adjusted odds ratios (and 95% confidence intervals) were 4.88 (4.72-5.05), 4.20 (4.03-4.37), and 3.81 (3.63-3.99), respectively. Similar patterns were observed for 30- and 60-day mortality. There were no sizable differences in complication rates for patients readmitted within 5 days versus after 21 days (24.8% vs 26.2%, P < 0.001). CONCLUSIONS: Surgical readmissions within 10 days of discharge are disproportionately common and associated with increased mortality independent of index complications. These findings suggest 10-day readmissions should be specially targeted by quality improvement efforts.

Reliability of hospital readmission rates in vascular surgery.

OBJECTIVE: The Center for Medicare and Medicaid Services recently began assessing financial penalties to hospitals with high readmission rates for a narrow set of medical conditions. Because these penalties will be extended to surgical conditions in the near future, we sought to determine whether readmissions are a reliable predictor of hospital performance with vascular surgery. METHODS: We examined 4 years of national Medicare claims data from 1576 hospitals on beneficiaries undergoing three common vascular procedures: open or endovascular abdominal aortic aneurysm repair (n = 81,520) or lower extremity arterial bypass (n = 57,190). First, we divided our population into two groups on the basis of operative date (2005-2006 and 2007-2008) and generated hospital risk- and reliability-adjusted readmission rates for each time period. We evaluated reliability through the use of the "test-retest" method; highly reliable measures will show little variation in rates over time. Specifically, we evaluated the year-to-year reliability of readmissions by calculating Spearman rank correlation and weighted κ tests for readmission rates between the two time periods. RESULTS: The Spearman coefficient between 2005-2006 readmissions rankings and 2007-2008 readmissions rankings was 0.57 (P < .001) and weighted κ was 0.42 (P < .001), indicating a moderate correlation. However, only 32% of the variation in hospital readmission rates in 2007-2008 was explained by readmissions during the 2 prior years. There were major reclassifications of hospital rankings between years, with 63% of hospitals migrating among performance quintiles between 2005-2006 and 2007-2008. CONCLUSIONS: Risk-adjusted readmission rates for vascular surgery vary substantially year to year; this implies that much of the observed variation in readmission rates is either random or caused by unmeasured factors and not caused by changes in hospital quality that may be captured by administrative data.

Validating administratively derived frailty scores for use in Veterans Health Administration emergency departments.

OBJECTIVES: Frailty is a clinical syndrome characterized by decreased physiologic reserve that diminishes the ability to respond to stressors such as acute illness. Veterans Health Administration (VA) emergency departments (ED) are the primary venue of care for Veterans with acute illness and represent key sites for frailty recognition. As questionnaire-based frailty instruments can be cumbersome to implement in the ED, we examined two administratively derived frailty scores for use among VA ED patients. METHODS: This national retrospective cohort study included all VA ED visits (2017-2020). We evaluated two administratively derived scores: the Care Assessment Needs (CAN) score and the VA Frailty Index (VA-FI). We categorized all ED visits across four frailty groups and examined associations with outcomes of 30-day and 90-day hospitalization and 30-day, 90-day, and 1-year mortality. We used logistic regression to assess the model performance of the CAN score and the VA-FI. RESULTS: The cohort included 9,213,571 ED visits. With the CAN score, 28.7% of the cohort were classified as severely frail; by VA-FI, 13.2% were severely frail. All outcome rates increased with progressive frailty (p-values for all comparisons < 0.001). For example, for 1-year mortality based on the CAN score frailty was determined as: robust, 1.4%; prefrail, 3.4%; moderately frail, 7.0%; and severely frail, 20.2%. Similarly, for 90-day hospitalization based on VA-FI, frailty was determined as prefrail, 8.3%; mildly frail, 15.3%; moderately frail, 29.5%; and severely frail, 55.4%. The c-statistics for CAN score models were higher than for VA-FI models across all outcomes (e.g., 1-year mortality, 0.721 vs. 0.659). CONCLUSIONS: Frailty was common among VA ED patients. Increased frailty, whether measured by CAN score or VA-FI, was strongly associated with hospitalization and mortality and both can be used in the ED to identify Veterans at high risk for adverse outcomes. Having an effective automatic score in VA EDs to identify frail Veterans may allow for better targeting of scarce resources.

Prevalence and associations of incidental nonvenous duplex findings discovered during lower extremity venous imaging.

OBJECTIVE: Venous duplex imaging defines venous pathology (VP). Unexpected clinically relevant findings are also found but rarely mentioned in the literature. This study aims to define the prevalence of ancillary findings (nonvenous duplex) by study type and venous outcome and subgroup associations with primary study indication and risk factors. METHODS: Our vascular laboratory database was queried for lower extremity venous duplex studies with comments regarding ancillary findings and associated patient demographics, primary study indication, associated conditions, and venous study outcome. RESULTS: There were 52,215 venous studies performed, 48,425 to evaluate for venous occlusion (acute/chronic) and 3790 for venous reflux. Of these studies, 15,810 found VP and 36,405 found no venous disease. There were 875 studies with venous disease that had ancillary duplex findings (5.5%) noted as 559 (3.5%) with prominent lymph node(s) (LN), 179 (1.1%) Baker's cyst (BC), 44 (0.3%) hematoma/mass (HM), 31 (0.2%) arterial aneurysm, and 16 (0.1%) arterial occlusion. There were 3130 studies free of VP with ancillary findings (8.6%) noted as 2258 (6.2%) prominent LN(s), 626 (1.7%) BC, 156 (0.4%) HM, 37 (0.1%) arterial aneurysm, and 22 (0.06%) arterial occlusion. The overall prevalence of ancillary findings was 8.62%. Analysis demonstrated statistically more ancillary findings in venous occlusion (odds ratio [OR], 1.25) studies, which was the largest group at 13 to 1. Studies free of venous disease had more ancillary findings (P < .001) with an OR of 1.88 and similar results were noted for LN(s), BC, and hematoma. Studies with VP favored a finding of aneurysm (OR, 0.52). Subgroup analyses demonstrated that those with prominent LN(s) were statistically older and male and BC statistically older in those with coexistent venous disease. BC subgroup analysis showed that studies free of venous disease were 2.5 times more likely to report pain as the primary study indication (P < .0001). In general, within ancillary subgroups, leg symptoms were statistically more prominent on the side with ancillary pathology and free of venous disease. CONCLUSIONS: Ancillary findings are not uncommon and are more common in studies found free of VP. The most common are LNs, BC and HM and, within subgroups, significant leg symptoms favors the presence of ancillary findings without coexisting venous disease. Ancillary findings should be an integral part of a quality report.

Effect of Index Hospitalization Costs on Readmission Among Patients Undergoing Major Abdominal Surgery.

IMPORTANCE: Reduction of postoperative readmissions has been identified as an opportunity for containment of health care costs. To date, the effect of index hospitalization costs on subsequent readmissions, however, has not been examined. OBJECTIVES: To identify the effect of index admission costs on readmission rates and to quantify any potential variation in costs and readmission attributable to the patient, procedure, and surgeon. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of the medical records of 4114 patients who underwent a colorectal, pancreatic, or hepatic resection from January 1, 2009, to December 31, 2013, at a tertiary care hospital. Readmission was defined as a second hospitalization within 30 days of discharge from the index hospitalization. Final follow-up was completed on April 24, 2014, and data were analyzed from July 1 to August 1, 2015. MAIN OUTCOMES AND MEASURES: Total inpatient costs of the index hospitalization and readmission rates. RESULTS: Among 4114 patients who met inclusion criteria (2122 women [51.6%] and 1992 men [48.4%]; median [interquartile range (IQR)] age, 59 [49-69] years), 1760 (42.8%) underwent colorectal resection; 1660 (40.4%), pancreatic resection; and 694 (16.9%), hepatic resection. Seven hundred seven patients were readmitted within 30 days (unadjusted readmission rate, 17.2%), including 328 patients (18.6%) for colorectal procedures, 309 patients (18.6%) for pancreatic procedures, and 70 patients (10.1%) for hepatic procedures (P < .001). The median cost of surgery during the index hospitalization was $24 992 and varied by procedure (colorectal, $22 186; pancreatic, $29 175; hepatic, $22 757; P < .001). The median index length of stay was 7 (IQR, 5-11) days and was higher among patients who were eventually readmitted (8 [IQR, 6-13] vs 7 [IQR, 5-11] days; P < .001). Readmitted patients had a higher incidence of perioperative morbidity during the index hospitalization (169 of 707 [23.9%] vs 662 of 3407 [19.4%]; P = .007). On adjusted analysis, an independent association with a higher risk for readmission was found for African American patients (odds ratio [OR], 1.45; 95% CI, 1.17-1.81), those undergoing pancreatic (OR, 1.99; 95% CI, 1.50-2.63) or colorectal (OR, 1.93; 95% CI, 1.46-2.55) resection, and patients with an observed-to-expected index length of stay of greater than 1 (OR, 1.26; 95% CI, 1.05-1.54) (P ≤ .001 for all). Total index hospitalization costs were higher among patients who were readmitted ($21 312 vs $24 321; P < .001). Further, among patients without a complication during the index hospitalization, total costs remained higher among patients who were eventually readmitted ($26 799 vs $22 462; P < .001). At the surgeon level, readmission rates varied among surgeons performing the same procedure (0%-33% among colorectal surgeons, 13%-38%% among pancreatic surgeons, and 8%-33% among hepatic surgeons; P < .001). Similarly, substantial variation in index hospitalization costs was also observed among surgeons performing the same procedure (coefficient of variation, 118.4% for colorectal, 89.0% for pancreatic, and 85.0% for hepatic). CONCLUSIONS AND RELEVANCE: Thirty-day readmission rates among patients undergoing major abdominal surgery vary significantly. Higher index hospitalization costs did not translate into lower readmission rates.

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

BACKGROUND: Since October of 2012, Medicare's Hospital Readmissions Reduction Program has fined 2,200 hospitals a total of $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 Medicare's 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.

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.