Examining the surgical stress effects (SSE) framework in practice: A qualitative assessment of perceived sources and consequences of intraoperative stress in surgical teams.

BACKGROUND: Surgical adverse events persist despite extensive improvement efforts. Emotional and behavioral responses to stressors may influence intraoperative performance, as illustrated in the surgical stress effects (SSE) framework. However, the SSE has not been assessed using "real world" data. METHODS: We conducted semi-structured interviews with all surgical team roles at one midwestern VA hospital and elicited narratives involving intraoperative stress. Two coders inductively identified codes from transcripts. The team identified themes among codes and assessed concordance with the SSE framework. RESULTS: Throughout 28 interviews, we found surgical stress was ubiquitous, associated with a variety of factors, including adverse events. Stressors often elicited frustration, anger, fear, and anxiety; behavioral reactions to negative emotions frequently were perceived to degrade individual/team performance and compromise outcomes. Narratives were consistent with the SSE framework and support adding a process outcome (efficiency) and illustrating how adverse events can feedback and acutely increase job demands and stress. CONCLUSION: This qualitative study describes narratives of intraoperative stress, finding they are consistent with the SSE while also allowing minor improvements to the current framework.

Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations.

BACKGROUND: The surgical profession is plagued with a high prevalence of work-related musculoskeletal disorders. While numerous interventions have been tested over the years, surgical ergonomics education is still uncommon. METHODS: The available literature on surgical ergonomics was reviewed, and with input from surgeons, recommendations from the review were used to create pictorial reminders for open, laparoscopic, and robot-assisted surgical modalities. These simple pictorial ergonomic recommendations were then assessed for practicality by residents and surgeons. RESULTS: A review of the current literature on surgical ergonomics covered evidence-based ergonomic recommendations on equipment during open and laparoscopic surgery, as well as proper adjustment of the surgical robot for robot-assisted surgeries. Ergonomic operative postures for the three modalities were examined, illustrated, and assessed. CONCLUSIONS: The resulting illustrations of ergonomic guidelines across surgical modalities may be employed in developing ergonomic education materials and improving the identification and mitigation of ergonomic risks in the operating room.

Optimizing Outcomes in Urological Surgery: Postoperative Care.

INTRODUCTION: Understanding best practices in perioperative care is critical for quality of care for our urology patients. We compiled a single, concise resource that provides recommendations for optimizing postoperative outcomes in patients undergoing urological surgery. METHODS: Optimal postoperative care includes minimizing complications, optimizing recovery and improving patient outcomes. The assembled White Paper multidisciplinary writing team included experts in a number of different areas (urologists, nurses, anesthesiologists) to address a comprehensive set of topics that urological providers face when caring for postoperative patients. This article provides a summary of key elements to optimize postoperative care in adult urological surgery, including in-hospital considerations, transition/discharge, and followup and surveillance. RESULTS: In-hospital postoperative considerations include checklists, handoffs for safe transitions from the anesthesia to surgical team, level of care planning and enhanced recovery after surgery (ERAS®). Embedded in ERAS are postoperative nutrition, mobilization, wound care, judicious use of catheters and drains, and postoperative medications and transfusions. As the patient transitions to the outpatient setting, the urologist must provide clear and readable postoperative education, which includes medication management and coordinated followup with primary care providers and home health as needed. Finally, followup visits should be carefully considered using innovative methods such as telehealth and patient reported outcomes to elevate postoperative and long-term care. CONCLUSIONS: This article summarizes postoperative factors that may impact surgical outcomes in urology. By understanding and applying best practices for postoperative care, urologists can optimize the quality of care for their patients.

Optimizing Outcomes in Urologic Surgery: Intraoperative Environmental, Behavioral, and Performance Considerations.

INTRODUCTION: Intraoperative surgical outcomes are influenced by a wide variety of environmental, provider and institutional factors. There is little in the current literature that provides guidance for practitioners interested in adapting these factors to improve the quality of the urological care they provide. METHODS: A multidisciplinary panel of subject matter experts (urologists, nurses, anesthesiologists) was convened to evaluate the existing literature, create a white paper, and disseminate this to providers and institutions to fuel quality improvement efforts in urological surgery. Focusing on intraoperative environmental, behavioral and performance factors, a narrative review was performed, highlighting practical interventions when available. RESULTS: Intraoperative performance is optimized by encouraging a culture of safety, improving intraoperative teamwork, thoughtfully navigating conflict and disruptive behavior, improving surgeon ergonomics, minimizing noise/distractions and engaging in ongoing technical performance improvement. In addition, practical tools are provided to assist in the challenging task of quality improvement in the surgical context. CONCLUSIONS: We summarize the influence of organizational culture, environment and behavior on surgical performance and outcomes. This work is intended to support local quality improvement efforts by educating the urological community regarding less well-known environmental, behavioral and institutional factors that influence surgical performance and patient outcomes.

Optimizing Outcomes in Urological Surgery: Preoperative Care.

PURPOSE: Understanding best practices in preoperative care is critical for quality of care for our urology patients. We compiled a concise resource that provides recommendations for optimizing preoperative outcomes for patients undergoing urological surgery. MATERIALS AND METHODS: Urological preoperative care was defined as medical evaluation or treatment received in preparation for surgery or a procedure. The Preoperative White Paper Panel was comprised of practicing urologists and nurses. The topic was researched via literature published from 1980 through 2018 which focused on preoperative evaluation and safety. Best practice recommendations were also reviewed from specialty societies. Recommendations in this article reflect expert opinion from the Panel, and are based on review of available evidence and existing best practice statements. RESULTS: Preoperative optimization involves a good assessment and stratification of surgical risk for the patient about to undergo surgery or a procedure. This assessment starts with a timely history and physical evaluation, as well as review of underlying frailty and cognition. The assessment helps inform potential postoperative needs. Risk stratification calculators are available to determine potential cardiac and pulmonary morbidity as well as overall surgical risk. Optimization of endocrine and gastrointestinal comorbidities can also reduce complications for patients. Modifiable preoperative behaviors and needs such as malnutrition and smoking cessation should also be discussed before surgery. CONCLUSIONS: We summarize the preoperative factors that may impact surgical outcomes in urology. By understanding and applying best practices for preoperative care, urologists can optimize the quality of care for their patients.

Optimizing Outcomes in Urological Surgery: Intraoperative Patient Safety and Physiological Considerations.

INTRODUCTION: Intraoperative surgical outcomes are influenced by a wide variety of patient, surgeon and institutional factors. The current literature lacks comprehensive resources that describe best practices in preventing patient safety events and optimizing patient physiology during urological surgery. METHODS: A multidisciplinary panel of subject matter experts (urologists, nurses, anesthesiologists) was convened to evaluate the existing literature, create a white paper and disseminate this to urological providers. Focusing on intraoperative patient safety and physiology, a narrative review was undertaken and relevant guidelines and practical interventions were highlighted. RESULTS: Patient safety is optimized by preventing surgical site infections, wrong site surgery, venous thromboembolism, falls/positioning injuries, laser/fire injuries, excessive radiation exposure and harm from the adoption of new technology. Goals for intraoperative physiological parameters (temperature, glucose, fluid balance) are addressed as well as analgesic and anesthetic considerations in urological patients. In addition, practical tools are provided to assist in the quality improvement process. CONCLUSIONS: This article summarizes intraoperative factors related to patient safety and optimal physiology that can impact urological surgical outcomes. This overview can be used as a practical guide for process improvement to optimize the quality of intraoperative care.

Intraoperative Disruptive Behavior: The Medical Student's Perspective.

OBJECTIVE: Intraoperative disruptive behavior can reduce psychological safety and hinder teamwork and communication. Medical students may provide unique insights into how to prevent these adverse impacts. We sought to characterize medical student perspectives on the causes and consequences of intraoperative disruptive behavior and ideal intraoperative working environments. DESIGN: In this retrospective qualitative analysis, authors coded de-identified field notes from residency interviews to identify themes and key insights and to explore gender differences in perspectives. SETTING: A tertiary academic medical training center in the Midwestern United States. PARTICIPANTS: Forty-two medical students applying for urology residency placement. RESULTS: Students were 57% male with an average age of 26 years (range 23-34). Most students witnessed intraoperative disruptive behavior (usually by surgeons) such as yelling, throwing instruments, or blaming others. Students described frustration with missing instruments and incompetent assistants as the most common instigators of disruptive behavior. They noted undesirable effects of disruptive behavior, including decreased communication/teamwork, lack of learning, increased technical mistakes, and recalled feeling afraid and stressed by these situations. They described ideal intraoperative working environments as calm, efficient and collaborative environments where questioning and learning is encouraged. CONCLUSIONS: Students provide a valuable perspective on the causes and consequences of disruptive behavior during surgery and point to potential pathways to improvement. Their experiences suggest prevention or reduction of surgeon frustration might be a fruitful target for intervention efforts to prevent intraoperative disruption.

The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework.

BACKGROUND: Surgical adverse events persist despite several decades of system-based quality improvement efforts, suggesting the need for alternative strategies. Qualitative studies suggest stress-induced negative intraoperative interpersonal dynamics might contribute to performance errors and undesirable patient outcomes. Understanding the impact of intraoperative stressors may be critical to reducing adverse events and improving outcomes. DATA SOURCES: We searched MEDLINE, psycINFO, EMBASE, Business Source Premier, and CINAHL databases (1996-2016) to assess the relationship between negative (emotional and behavioral) responses to acute intraoperative stressors and provider performance or patient surgical outcomes. RESULTS/CONCLUSIONS: Drawing on theory and evidence from reviewed studies, we present the Surgical Stress Effects (SSE) framework. This illustrates how emotional and behavioral responses to stressors can influence individual surgical provider (e.g. surgeon, nurse) performance, team performance, and patient outcomes. It also demonstrates how uncompensated intraoperative threats and errors can lead to adverse events, highlighting evidence gaps for future research efforts.

Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening.

INTRODUCTION: The American Urological Association Quality Improvement Summit occurs regularly to provide education and promote dialogue around the issues of quality improvement and patient safety. Nearly all prostate cancer screening guidelines recommend shared decision making strategies when determining whether prostate specific antigen testing is right for a specific patient. This summit, held in partnership with the Society for Medical Decision Making, focused on techniques to identify and understand patient values in relation to prostate cancer screening and treatment, and to promote incorporation of shared decision making into prostate cancer screening discussions. METHODS: Information presented at the Quality Improvement Summit was provided by physicians and leading experts in the field of shared decision making. The open forum of this summit encouraged contributions from participants about their personal experiences with shared decision making and their thoughts on the tools presented during the day. RESULTS: Shared decision making supports collaboration between physician and patient in situations where there are multiple preference sensitive options. CONCLUSIONS: Practitioners should include formal shared decision making procedures surrounding prostate specific antigen testing in their practices to ensure that testing is in accordance with patient values and desired outcomes. Tools and strategies like those reviewed in this Quality Improvement Summit are invaluable for alleviating potential burden on providers, ensuring communication and improving quality of care.

Similar perspectives on prostate cancer screening value and new guidelines across patient demographic and PSA level subgroups: A qualitative study.

BACKGROUND: In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based prostate cancer screening for all men. OBJECTIVE: To inform educational materials addressing patient questions and concerns about the 2012 USPSTF guidelines, we sought to: (i) characterize patient perceptions about prostate cancer screening benefits, harms and recommendations against screening, and (ii) compare perceptions across race, age and PSA level subgroups. METHODS: We conducted qualitative interviews with a sample of 26 men from the Minneapolis Veterans Affairs Health Care System, stratified by race (African American, other), age (50-69, 70-84) and PSA level (documented PSA level ≥4 in Veterans Health Administration electronic medical records vs no such documentation). We used an inductive approach informed by grounded theory to analyse transcribed interviews. RESULTS: Most men in all subgroups expressed misperceptions about the benefits of prostate cancer screening and had difficulty identifying harms associated with screening. In all subgroups, reactions to recommendations against screening ranged from unconditionally receptive to highly resistant. Some men in every subgroup initially resistant to the idea said they would accept a recommendation to discontinue screening from their provider. CONCLUSIONS: Given the similarity of perceptions and reactions across subgroups, materials targeted by race, age and PSA level may not be necessary. Efforts to inform decision making about prostate cancer screening should address misperceptions about benefits and lack of awareness of harms. Provider perspectives and recommendations may play a pivotal role in shaping patient reactions to new guidelines.

Defining the publication source of high-quality evidence in urology: an analysis of EvidenceUpdates.

OBJECTIVES: To determine the publication sources of urology articles within EvidenceUpdates, a second-order peer review system of the medical literature designed to identify high-quality articles to support up-to-date and evidence-based clinical decisions. MATERIALS AND METHODS: Using administrator-level access, all EvidenceUpdates citations from 2005 to 2014 were downloaded from the topics 'Surgery-Urology' and 'Oncology-Genitourinary'. Data fields accessed included PubMed unique reference identifier, study title, abstract, journal and date of publication, as well as clinical relevance and newsworthiness ratings as determined by discipline-specific physician raters. The citations were then coded by clinical topic (oncology, voiding dysfunction, erectile dysfunction/infertility, infection/inflammation, stones/endourology/laparoscopy, trauma/reconstruction, transplant, or other), journal category (general medical journal, oncology journal, urology journal, non-urology specialty journal, Cochrane review, or other), and study design (randomised controlled trial [RCT], systematic review, observational study, or other). Articles that were perceived to be misclassified and/or of no direct interest to urologists were excluded. Descriptive statistics using proportions and 95% confidence intervals, as well as means and standard deviations (SDs) were used to characterise the overall data cohort and to analyse trends over time. RESULTS: We identified 731 unique citations classified under either 'Surgery-Urology' or 'Oncology-Genitourinary' for analysis after exclusions. Between 2005 and 2014, the most common topics were oncology (48.6%, 355 articles) and voiding dysfunction (21.8%, 159). Within the topic of oncology, prostate cancer contributed over half the studies (54.6%, n = 194). The most common study types were RCTs (42.3%, 309 articles) and systematic reviews (39.6%, 290). Systematic reviews had a nearly fourfold relative increase within less than a decade. The largest proportion of studies relevant to urology were published in general oncology journals (20.0%, n = 146), followed by the Cochrane Library (19.3%, n = 141) and general medical journals (17.2%, n = 126). Urology-specific journals contributed to only approximately one-tenth of EvidenceUpdates alerts (9.4%, n = 69), with the highest contribution occurring during the 2013/2014 period. For clinical relevance and newsworthiness scores (each graded on scales of 1-7), urology journals scored the highest in clinical relevance with a mean (SD) of 5.9 (0.75) and general medical journals scored highest for newsworthiness at 5.3 (0.94). On average, RCTs scored highest both for clinical relevance and newsworthiness with mean (SD) scores of 5.71 (0.81) and 5.22 (0.91), respectively. CONCLUSION: A large number of high-quality, clinically relevant, and newsworthy peer-reviewed urology publications are published outside of traditional urology journals. This requires urologists to implement well-defined strategies to stay abreast of current best evidence.

Multi-Institutional Validation of an OSATS for the Assessment of Cystoscopic and Ureteroscopic Skills.

PURPOSE: We evaluated the internal and construct validity of an assessment tool for cystoscopic and ureteroscopic cognitive and psychomotor skills at a multi-institutional level. MATERIALS AND METHODS: Subjects included a total of 30 urology residents at Ohio State University, Columbus, Ohio; Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Mayo Clinic, Rochester, Minnesota. A single external blinded reviewer evaluated cognitive and psychomotor skills associated with cystoscopic and ureteroscopic surgery using high fidelity bench models. Exercises included navigation, basketing and relocation; holmium laser lithotripsy; and cystoscope assembly. Each resident received a total cognitive score, checklist score and global psychomotor skills score. Construct validity was assessed by calculating correlations between training year and performance scores (both cognitive and psychomotor). Internal validity was confirmed by calculating correlations between test components. RESULTS: The median total cognitive score was 91 (IQR 86.25, 97). For psychomotor performance residents had a median total checklist score of 7 (IQR 5, 8) and a median global psychomotor skills score of 21 (IQR 18, 24.5). Construct validity was supported by the positive and statistically significant correlations between training year and total cognitive score (r = 0.66, 95% CI 0.39-0.82, p = 0.01), checklist scores (r = 0.66, 95% CI 0.35-0.84, p = 0.32) and global psychomotor skills score (r = 0.76, 95% CI 0.55-0.88, p = 0.002). The internal validity of OSATS was supported since total cognitive and checklist scores correlated with the global psychomotor skills score. CONCLUSIONS: In this multi-institutional study we successfully demonstrated the construct and internal validity of an objective assessment of cystoscopic and ureteroscopic cognitive and technical skills, including laser lithotripsy.

A novel multispecialty surgical risk score for children.

BACKGROUND AND OBJECTIVE: There is a lack of broadly applicable measures for risk adjustment in pediatric surgical patients necessary for improving outcomes and patient safety. Our objective was to develop a risk stratification model that predicts mortality after surgical operations in children. METHODS: The model was created by using inpatient databases from 1988 to 2006. Patients younger than 18 years who underwent an inpatient surgical procedure as identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification, coding were included. A 7-point scale was developed with 70 variables selected for their predictive value for mortality using multivariate analysis. This model was evaluated with receiver operating characteristic (ROC) analysis and compared with the Charlson Comorbidity Index (CCI) in two separate validation data sets. RESULTS: A total of 2 087 915 patients were identified in the training data set. Generated risk scores positively correlated with inpatient mortality. In the training data set, the ROC was 0.949 (95% confidence interval [CI]: 0.947, 0.950). In the first validation data set, the ROC was 0.959 (95% CI: 0.952, 0.967) compared with the CCI ROC of 0.596 (95% CI: 0.575, 0.616). In the second validation data set, the ROC was 0.901 (95% CI: 0.885, 0.917) and the CCI ROC was 0.587 (95% CI: 0.562, 0.611). CONCLUSIONS: This study depicts creation of a broadly applicable model for risk adjustment that predicts inpatient mortality with more reliability than current risk indexes in pediatric surgical patients. This risk index will allow comorbidity-adjusted outcomes broadly in pediatric surgery.

Evaluating metrics for quality: death on the same day of elective pediatric surgery.

Surgical mortality is considered a benchmark for measuring quality of care. This study quantifies the incidence of death on the day of elective pediatric surgery, which generally is considered preventable and might be considered a "never" event. The authors conducted a retrospective analysis of national state inpatient databases from 1988 to 2007 that included elective pediatric surgical patients. A descriptive analysis of same-day mortality by demographics, surgical specialties, and age was performed. Of 835 880 elective pediatric surgical cases identified, 174 patients died on the day of surgery-that is, 2.1 deaths/10 000 cases. Surgical specialty mortality rates ranged from 0.06 (otolaryngology) to 17.4 (cardiothoracic surgery) deaths per 10 000 cases. Death on the day of elective pediatric surgery is rare, limiting its utility to compare performance in pediatric surgery. However, this metric may be useful at individual institutions as a case-finding tool for root-cause analysis in quality improvement efforts.

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators.

BACKGROUND/PURPOSE: Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux. METHODS: A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ(2) tests and t tests. RESULTS: Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open. CONCLUSION: Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.

Priapism in the United States: the changing role of sickle cell disease.

BACKGROUND: Few patients with priapism require inpatient management unless they are refractory to intracavernosal therapy. Their risk factors and outcomes are poorly characterized. METHODS: This is a retrospective analysis of the Nationwide Inpatient Sample (1998-2006). Priapism patients were identified and analyzed over time by age, race, sickle-cell disease diagnosis, drug abuse, and penile operations. RESULTS: A total of 4,237 hospitalizations for priapism were identified (30% white, 61.1% black, and 6.3% Hispanics). There was an increasing incidence of priapism over time, concentrated in the middle-age group. There were 1,776 patients (41.9%) with diagnoses of sickle-cell disease, with decreasing proportions over time. Drug abuse was reported in 7.9%. CONCLUSIONS: Inpatient diagnoses of priapism are increasing over time with relatively constant numbers of sickle-cell disease patients, suggesting rising nonhematologic causes of priapism. One theory is that increasing use of aggressive therapies for erectile dysfunction might play a role, especially when combined with drug abuse.

Validation of the World Health Organization tool for situational analysis to assess emergency and essential surgical care at district hospitals in Ghana.

BACKGROUND: The World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (hereafter called the WHO Tool) has been used in more than 25 countries and is the largest effort to assess surgical care in the world. However, it has not yet been independently validated. Test-retest reliability is one way to validate the degree to which tests instruments are free from random error. The aim of the present field study was to determine the test-retest reliability of the WHO Tool. METHODS: The WHO Tool was mailed to 10 district hospitals in Ghana. Written instructions were provided along with a letter from the Ghana Health Services requesting the hospital administrator to complete the survey tool. After ensuring delivery and completion of the forms, the study team readministered the WHO Tool at the time of an on-site visit less than 1 month later. The results of the two tests were compared to calculate kappa statistics for each of the 152 questions in the WHO Tool. The kappa statistic is a statistical measure of the degree of agreement above what would be expected based on chance alone. RESULTS: Ten hospitals were surveyed twice over a short interval (i.e., less than 1 month). Weighted and unweighted kappa statistics were calculated for 152 questions. The median unweighted kappa for the entire survey was 0.43 (interquartile range 0-0.84). The infrastructure section (24 questions) had a median kappa of 0.81; the human resources section (13 questions) had a median kappa of 0.77; the surgical procedures section (67 questions) had a median kappa of 0.00; and the emergency surgical equipment section (48 questions) had a median kappa of 0.81. CONCLUSIONS: Hospital capacity survey questions related to infrastructure characteristics had high reliability. However, questions related to process of care had poor reliability and may benefit from supplemental data gathered by direct observation. Limitations to the study include the small sample size: 10 district hospitals in a single country. Consistent and high correlations calculated from the field testing within the present analysis suggest that the WHO Tool for Situational Analysis is a reliable tool where it measures structure and setting, but it should be revised for measuring process of care.

Cost of inpatient care and its association with hospital competition.

BACKGROUND: Conventional economic principles suggest that increases in competition are associated with price decreases. The purpose of this study is to determine whether this association holds true between objective measures of hospital competition and gross charges, by analyzing standardized operations where variations in costs should be minimal. STUDY DESIGN: Hospital Market Structure file (from Agency for Healthcare Research and Quality, available for years 2000 and 2003) was linked to Nationwide Inpatient Sample database. Appendectomy, carotid endarterectomy, bariatric surgery, radical prostatectomy, and pyloromyotomy were analyzed, after excluding patients with possible complications. Primary outcomes included total hospital charges. Primary independent variable was Herfindahl-Hirschman Index (HHI) calculated by the Agency for Healthcare Research and Quality for each hospital based on its patient-flow market. Higher HHI represents the presence of more dominant hospitals in the market or lower competition. RESULTS: A total of 162,823 patients from 1,492 hospitals (85,791 appendectomies, 38,619 carotid endarterectomies, 18,383 bariatric operations, 16,784 radical prostatectomies, 3,246 pyloromyotomies) were analyzed. Single linear regression analyses demonstrated higher HHI was significantly associated with lower hospital gross charges in all cases. On multivariate analysis, a 1 percentage-point increase on HHI was associated with -$114 for appendectomy, -$163 for carotid endarterectomy, and -$193 for radical prostatectomy (all p ≤ 0.001), and were independent of hospital urbanicity, teaching status, and payer mix. In contrast, no association was found between competition and hospital costs. CONCLUSIONS: Higher level of hospital competition is associated with higher hospital gross charges, although competition intensity is not associated with hospital costs. These data are important as health policy makers consider possible cost-control measures.