What Happens to Full Mouth Extraction Patients? A Retrospective Review of Patient Mortality at an Academic Medical Center.

PURPOSE: When providers are forced to address the growing oral healthcare needs of an aging and sick population, full mouth extractions (FMEs) are often sought as a solution. The purpose of this observational study was to evaluate mortality rates, mortality timeline, and to identify associated risk factors. METHODS: A single-center retrospective cohort study was conducted at the University of Cincinnati Medical Center. All patients who underwent FMEs at the Oral and Maxillofacial Surgery clinic from July 1, 2012 to December 31, 2019 due to caries or periodontal disease were included. Predictor variables recorded included a medical history, social history, and patient demographics. The main outcome variable was post-FME death, including the elapsed time from procedure to death. Deaths were identified using the National Death Index. Data were analyzed using simple descriptive statistics and Cox proportional hazard models. Deceased FME patients were compared to living FME patients to identify potential risk factors. Mortality risk index was derived from multivariable logistic regression. RESULTS: One thousand eight hundred twenty nine patients were included in the study. Nine hundred seventy six were female with a median age of 49 years (interquartile range 38-58). One thousand seven hundred nine were diagnosed with more than 1 comorbidity and 89% were on medicaid or medicare insurance. One hundred seventy patients (9.3%) were identified as deceased as of December 31, 2019. Of those who died, 87 patients were deceased within 2 years of the procedure and 147 within 5 years of the procedure. Statistically significant factors associated with mortality (P value < .01) included age (hazards ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.03), ASA score >3 (HR 3.12, 95% CI 2.2-4.42), nursing home residence (HR 2.66, 95% 1.67-4.28), hepatic disease (HR 1.81, 95% CI 1.18-2.78), and oncologic disease (HR 1.91, 95% 1.32-2.77). CONCLUSIONS: Approximately 1 in 10 patients died within 5 years of FME at our center. These patients may be medically and socially compromised. More research is needed to develop FME-specific mortality indices, which may serve useful for clinical decision-making and surgical palliative care.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals.

BACKGROUND: Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS: The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS: Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION: For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.

Surviving rectal cancer: examination of racial disparities surrounding access to care.

BACKGROUND: The aim of this study was to evaluate whether survival differences are attributable to disproportionate access to stage-specific rectal cancer treatment recommended by the National Comprehensive Care Network. METHODS: A retrospective analysis of the National Cancer Data Base between 1998 and 2006 was performed. A series of Kaplan-Meier survival analyses were used to compare 5-y survival among race cohorts. Propensity score matching was used to compare Caucasian and African American patients who received the same treatment by accounting for covariates. RESULTS: 5-y overall survival in African Americans was 50.7% versus 56.2% in Caucasians (P < 0.001). In patients with stage I-III disease, 5-y survival was 58.7% in African Americans versus 63.1% in Caucasians (P < 0.001). Analysis of patients receiving surgery for stage I-III disease, revealed a 61.1% 5-y survival in African Americans versus 65.8% in Caucasians (P < 0.001). Propensity score matching did not eliminate the racial disparity. The median survival for Caucasian patients was 109.6 mo as compared to 85.8 mo for African Americans (P < 0.001). CONCLUSIONS: These data show that access to standard care appears to decrease but not eliminate the survival differences between African Americans and Caucasians with rectal cancer.

Opportunities to Improve Care of Hepatocellular Carcinoma in Vulnerable Patient Populations.

BACKGROUND: Hepatocellular carcinoma (HCC) patients with Medicaid or no health insurance have inferior survival compared with privately insured patients. Safety-net hospitals that care for these patients are often criticized for their inferior outcomes. We hypothesized that HCC survival was related to appropriate surgical management. STUDY DESIGN: The American College of Surgeons National Cancer Database was queried for patients diagnosed with HCC (n = 111,481) from 1998 to 2010. Hospitals were stratified according to safety-net burden, defined as the percentage of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared with lower-burden hospitals with regard to patient demographics, cancer presentation, surgical management, and survival. RESULTS: Patients at safety-net hospitals were less often white, had less income and education, but presented with similar stage HCC. Safety-net hospital patients were less likely to receive surgery (odds ratio 0.77; p < 0.01), and among curable patients (stages 1 and 2) who underwent surgical intervention, liver transplantation and resection were performed less often at safety-net hospitals than at other hospitals (50.7% vs 66.7%). Procedure-specific mortality rates were also higher at safety net hospitals (p < 0.01). However, multivariate analysis adjusting for cancer stage and type of surgery revealed similar survival for safety-net hospital patients who had surgery and survived for longer than 30 days (p = 0.73). CONCLUSIONS: Vulnerable patients with HCC are commonly treated at safety-net hospitals, are less likely to receive curative surgery, and have worse short-term outcomes. However, safety-net patients who can endure liver surgery have a similar prognosis as patients at nonsafety-net hospitals. Providing equal access to surgery may improve survival for vulnerable populations of HCC patients.

Pancreas fistula risk prediction: implications for hospital costs and payments.

BACKGROUND: As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS: A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS: Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION: Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.

Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals.

Importance: Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care. Objective: To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals. Design, Setting, and Participants: Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost. Main Outcomes and Measures: Overall cost per patient after PD. Results: During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost $35 303 per patient, 30.1% and 36.2% higher than at MBHs ($27 130) and LBHs ($25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to $4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of $9155 per HBH patient, or $699 per patient overall. Conclusions and Relevance: Safety-net hospitals performing PD have inferior outcomes and higher costs, and improving perioperative outcomes may have a nominal effect on reducing these costs. Redirecting patients away from safety-net hospitals for complex surgery may represent the best option for reducing costs, but the implementation of such a policy will undoubtedly meet significant challenges.

Hospital resources are associated with value-based surgical performance.

BACKGROUND: We have previously shown that inferior outcomes at safety-net hospitals are largely dependent on hospital factors. We hypothesized that hospitals providing "high value" care (low cost and better outcomes) would have advantages in human and financial resources. METHODS: The University HealthSystems Consortium Clinical Database and the American Hospital Association Annual Survey were used to examine hospitals performing eight complex surgical procedures from 2009 to 2013. Hospitals in the lowest quartiles of both mortality rate and cost were characterized as high value (n = 45), whereas those in the highest quartiles of both cost and mortality were low value (n = 45). Hospital size, staffing, and financial characteristics were compared between these two groups. RESULTS: On average, high-value hospitals had lower proportions of Medicaid patient days (17% versus 30%; P < 0.01), higher proportions of outpatient surgery (63% versus 53%; P < 0.01), and spent more on capital expenditures per bed ($155,710 versus $62,434; P < 0.05). Also, high-value hospitals employed more hospitalists (0.08 versus 0.04 per bed; P < 0.01), had more privileged physicians (2.04 versus 1.25 per bed; P < 0.01), and had more full-time equivalent personnel (8.48 versus 6.79 per bed; all P < 0.05). As a result, these hospitals appeared to be more efficient; high-value hospitals had more total admissions per bed (46 versus 38; P < 0.01), fewer days per admission (5.20 versus 5.77; P < 0.01), and more inpatient surgeries per bed (15.7 versus 12.6; all P < 0.05). CONCLUSIONS: Hospitals that invest in more human resources and demonstrate increased throughput perform complex surgery at higher "value" (i.e., lower costs and mortality). Value-based purchasing initiatives that link hospital reimbursement to unadjusted surgical outcomes may exacerbate, rather than improve, disparities in surgical care that currently exist.

Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery.

IMPORTANCE: Safety-net hospitals provide broad services for a vulnerable population of patients and are financially at risk owing to impending reimbursement penalties and policy changes. OBJECTIVE: To determine the effect of patient and hospital factors on surgical outcomes and cost at safety-net hospitals. DESIGN, SETTING, AND PARTICIPANTS: Hospitals in the University HealthSystem Consortium database from January 1, 2009, through December 31, 2012 (n = 31), were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time (n = 12,638,166). Nine cohorts, based on a variety of surgical procedures, were created and examined with regard to preoperative characteristics, postoperative outcomes, and resource utilization. Multiple logistic regression was performed to analyze the effect of patient and center factors on outcomes. Hospital Compare data from the Centers for Medicare & Medicaid Services were linked and used to characterize and compare the groups of hospitals. MAIN OUTCOMES AND MEASURES: Postoperative mortality, 30-day readmissions, and total direct cost. RESULTS: For all 9 procedures examined in 231 hospitals comprising 12,638,166 patient encounters, patients at hospitals with high safety-net burden (HBHs) (vs hospitals with low and medium safety-net burdens) were most likely to be young, to be black, to be of the lowest socioeconomic status, and to have the highest severity of illness and the highest cost for surgical care (P < .01 for all). For 7 of 9 procedures, HBHs had the highest proportion of emergent cases and longest length of stay (P < .01 for all). After adjusting for patient characteristics and center volume, HBHs still had higher odds of mortality for 3 procedures (odds ratios [ORs], 1.81-2.08; P < .05), readmission for 2 procedures (ORs, 1.19-1.30; P < .05), and the highest cost of care associated with 7 of 9 procedures (risk ratios, 1.23-1.35; P < .05). Analysis of Hospital Compare data found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency (all P < .05). CONCLUSIONS AND RELEVANCE: These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost across 9 elective surgical procedures. These outcomes are likely owing to hospital resources and not necessarily patient factors. In addition, impending changes to reimbursement may have a negative effect on the surgical care at these centers.

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care.

OBJECTIVE(S): Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs. METHODS: From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable. RESULTS: The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p < 0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48-3.07], p < 0.001), discharge to rehab (OR 1.84, [1.28-2.64], p < 0.001), home with home health care (OR 1.38, [1.08-1.76], p = 0.01), and surgery at a low-volume hospital (OR 1.49, [1.18-1.88], p < 0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53-0.85], p < 0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis. CONCLUSIONS: These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

Resource utilization in esophagectomy: When higher costs are associated with worse outcomes.

INTRODUCTION: Care of the esophagectomy patient requires significant resources. We sought to determine which patient and provider variables contribute to resource utilization and their association with clinical outcomes. METHODS: 6,737 patients undergoing esophagectomy were identified from the University Healthsystem Consortium (UHC). Linear and logistic regression models were used to determine whether characteristics, including age, severity of illness (SOI) and procedural volume were associated with mortality, length of stay (LOS), discharge disposition, readmission rates, and cost. RESULTS: Older patients were twice as likely to suffer post-operative death (OR 2.12; 95%CI 1.7-2.7), three times more likely to be discharged to extended care facilities (31.9% vs. 10.6%, P < 0.001), and cost 8.4% more ($27,628 vs. $25,481, P < 0.001). Similarly, patients with higher SOI were more likely to suffer post- operative death (OR 14.6; 4.7-45.9), be readmitted (OR 1.3; 1.1-1.6), and have longer hospital stays (RR 1.3; 1.8-2.1). Patients with the highest index hospital costs were five times more likely to be discharged to an extended care facility (P < 0.001). CONCLUSION: Older patients and those with a higher SOI have higher perioperative mortality, readmission rates, hospital costs, and require more post- operative care. With increasingly scrutinized health care costs, these data provide guidance for more careful patient selection.

Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation.

BACKGROUND: The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. METHODS: The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable. RESULTS: More than 19,500 patients populated the final dataset. Lower-quality kidneys (expanded criteria donor or KDPI 85+) were more likely to be transplanted in older (both P < .001) and diabetic recipients (both P < .001). After multivariable analysis controlling for recipient characteristics, we found that expanded criteria donor transplants were not associated with increased costs compared with standard criteria donor transplants (risk ratio [RR] 0.97, 95% confidence interval [CI] 0.93-1.00, P = .07). KDPI 85+ was associated with slightly lower costs than KDPI <85 transplants (RR 0.95, 95% CI 0.91-0.99, P = .02). When KDPI was considered as a continuous variable, the association was maintained (RR 0.9993, 95% CI 0.999-0.9998, P = .01). CONCLUSION: Organ quality metrics are less influential predictors of short-term costs than recipient factors. Future studies should focus on recipient characteristics as a way to discern high versus low cost transplantation procedures.

Readmission After Pancreaticoduodenectomy: The Influence of the Volume Effect Beyond Mortality.

BACKGROUND: As increased focus is placed on quality of care in surgery, readmission is an increasingly important metric by which hospital and surgeon quality is measured. For complex pancreatic surgery, we hypothesized that increased pancreaticoduodenectomy (PD) volume may mitigate readmission rates. METHODS: The University Healthsystems Consortium database was queried for all patients (n = 9805) undergoing PD from 2009 to 2011. Hospitals were stratified into quintiles based on number of cases performed annually. Univariate and multivariate logistic regression analyses were performed to identify factors associated with 30-day readmission. RESULTS: The 30-day readmission rate for patients undergoing PD was 19.1 %. Stratified by volume, hospitals performing the highest two quintiles of PDs annually (≥56 cases) had a significantly lower unadjusted readmission rate than those hospitals performing the lowest quintile (n ≤ 23 cases; 16.7 and 18.0 % vs. 20.9 %, p < 0.05). On univariate analysis, readmitted patients tended to have higher severity of illness (p < 0.01) and longer index admission (10 vs. 9 days, p < 0.01). Age and insurance status had no significant association with readmission. Multivariate analysis demonstrated that higher severity of illness (odds ratio [OR] 1.36, 95 % confidence interval [CI] 1.04-1.77, p = 0.02), discharge to rehab (OR 1.41, 95 % CI 1.19-1.66, p < 0.001), and surgery at the lowest volume hospitals (OR 1.28, 95 % CI 1.08-1.51, p = 0.004) were factors independently associated with readmission. CONCLUSIONS: Lower hospital volume is a significant risk factor for readmission after PD. To minimize the excess resource utilization that accompanies readmission, patients undergoing complex oncologic pancreatic surgery should be directed to hospitals most experienced in caring for this patient population.

Independent effect of black recipient race on short-term outcomes after liver transplantation.

BACKGROUND: Previous studies have demonstrated worse graft and patient survival for black patients after liver transplantation (LT), but these studies have not accounted properly for recipient, donor, center, or geographic effects. In this study, we evaluated the effect of candidate race on patient and graft survival after LT. METHODS: Using a novel linkage of the databases of the University Health System Consortium and the US Census and Scientific Registry of Transplant Recipients, we identified 12,445 patients (43.1% of total) who underwent LT in the United States from 2007 to 2011. Using a mixed-effects, proportional hazards model, we assessed the effect of race on patient and graft survival after controlling for recipient, donor, and center characteristics; region; donor service area; and individual transplant centers. RESULTS: At the time of transplantation, white patients were healthier, had a shorter duration of hospital stay, and a lesser in-hospital mortality compared with black and Hispanic patients. White recipients had a graft and patient survival advantage when compared with blacks, but there was no survival difference observed when compared with Hispanics. After controlling for recipient and donor characteristics, geographic region, donor service area, and the effect of the individual hospital, black recipients were still at an increased risk of both death (hazard ratio [HR], 1.31; 95% CI, 1.15-1.50) and graft failure (HR, 1.28; 95% CI, 1.14-1.44) after LT. CONCLUSION: After controlling for many of the important variables in the transplant process, including the individual hospital, black recipients were at increased risk of both death and graft failure after LT when compared with whites.

Cost discrepancies for common acute care surgery diagnoses in Ohio: influences of hospital characteristics on charge and payment differences.

BACKGROUND: Charge and payment discrepancies exist between hospitals, although such variation is understood incompletely. We hypothesized that hospital characteristics may account for such differences. METHODS: The 2011 Medicare Inpatient Prospective Payment System for Ohio hospitals was queried for discharge diagnoses of gastrointestinal bleed (GIB), GI obstruction (GIO), and laparoscopic cholecystectomy (LC). Analyses were performed to assess the association of hospital variables with charges and payments. RESULTS: For all three diagnoses, urban hospitals had greater median charges than rural hospitals; payments were not significantly different. Consequently, urban centers had lesser cost to charge ratios than rural centers for GIB, GIO, and LC: 0.29 versus 0.32 (P = .004), 0.27 versus 0.47 (P = .0007), and 0.26 versus 0.40 (P = .04), respectively. Centers with the greatest bed size had higher median charges and payments. Other discrepancies for all three diagnoses were greater payments at verified Level 1 centers and major teaching institutions (P value range <.0001 to .03). On multivariate analysis, excess charges were greater at urban centers for both GIB ($4,482, P = .02) and GIO ($5,700, P < .01). CONCLUSION: Hospital characteristics are associated with differences in charges and payments for acute care surgery diagnoses. Further study should investigate whether these cost discrepancies are associated with outcomes.

Is liver transplantation safe and effective in elderly (≥70 years) recipients? A case-controlled analysis.

BACKGROUND: Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outcomes in this group have not been well defined. METHODS: A linkage of the Scientific Registry of Transplant Recipients (SRTR) and the University HealthSystem Consortium (UHC) databases identified 12,445 patients who underwent LT during 2007-2011. Two cohorts were created consisting of, respectively, elderly recipients aged ≥70 years (n = 323) and recipients aged 18-69 years (n = 12,122). A 1:1 case-matched analysis was performed based on propensity scores. RESULTS: Elderly recipients had lower Model for End-stage Liver Disease (MELD) scores at LT (median 15 versus 19; P < 0.0001), more often underwent transplantation at high-volume centres (46% versus 33%; P < 0.0001) and more often received grafts from donors aged >60 years (24% versus 15%; P < 0.0001). The two cohorts had similar hospital lengths of stay, in-hospital mortality, hospital costs and 30-day readmission rates. There were no differences in graft survival between the two cohorts (P = 0.10), but elderly recipients had worse longterm overall survival (P = 0.009). However, a case-controlled analysis confirmed similar perioperative hospital outcomes, graft survival and longterm patient survival in the two matched cohorts. CONCLUSIONS: Elderly LT recipients accounted for <3% of all LTs performed during 2007-2011. Selected elderly recipients have perioperative outcomes and survival similar to those in younger adults.

Cost effectiveness after a pancreaticoduodenectomy: bolstering the volume argument.

BACKGROUND: The cost implication of variability in pancreatic surgery is not well described. It was hypothesized that for a pancreaticoduodenectomy (PD), lower volume centres demonstrate worse peri-operative outcomes at higher costs. METHODS: From 2009-2011, 9883 patients undergoing a PD were identified from the University HealthSystems Consortium (UHC) database and stratified into quintiles by annual hospital case volume. A decision analytic model was constructed to assess cost effectiveness. Total direct cost data were based on Medicare cost/charge ratios and included readmission costs when applicable. RESULTS: The lowest volume centres demonstrated a higher peri-operative mortality rate (3.5% versus 1.3%, P < 0.001) compared with the highest volume centres. When both index and readmission costs were considered, the per-patient total direct cost at the lowest volume centres was $23,005, or 10.9% (i.e. $2263 per case) more than at the highest volume centres. One-way sensitivity analyses adjusting for peri-operative mortality (1.3% at all centres) did not materially change the cost effectiveness analysis. Differences in cost were largely recognized in the index admission; readmission costs were similar across quintiles. CONCLUSIONS: For PD, low volume centres have higher peri-operative mortality rates and 10.9% higher cost per patient. Performance of PD at higher volume centres can lead to both better outcomes and substantial cost savings.

Predictors of conversion to thoracotomy for video-assisted thoracoscopic lobectomy: a retrospective analysis and the influence of computed tomography-based calcification assessment.

OBJECTIVE: Conversion to an open thoracotomy during video-assisted thoracoscopic surgery lobectomy is reported to occur in up to 23% of cases and can be associated with increased morbidity. We developed a preoperative computed tomography calcification score based on anatomic location and extent of calcifications to evaluate the ability to predict video-assisted thoracoscopic surgery conversion. METHODS: Patients undergoing planned video-assisted thoracoscopic surgery lobectomy between 2003 and 2009 were identified. Baseline demographics, comorbidities, operative data, and postoperative outcomes were reviewed. Preoperative chest computed tomography scans were examined by an attending thoracic surgeon. Calcifications were scored from 0 (none) to 6 (major hilar calcifications at the resection bronchus). Preoperative patient and tumor characteristics and the calcification score were analyzed for their ability to predict conversion. We then compared outcomes among patients undergoing video-assisted thoracoscopic surgery, converted video-assisted thoracoscopic surgery, and planned open thoracotomy. RESULTS: Of the 193 patients undergoing planned video-assisted thoracoscopic surgery lobectomy, 148 (77%) had a completed video-assisted thoracoscopic surgery lobectomy, and 45 (23%) underwent conversion to thoracotomy. The calcification score was found to independently predict video-assisted thoracoscopic surgery conversion. Patients who were converted to a thoracotomy had significantly higher 30-day mortality, more atrial arrhythmias, increased blood loss, longer operative time, and increased length of stay compared with those who underwent completed video-assisted thoracoscopic surgery lobectomy and longer length of stay compared with those undergoing planned open lobectomy. CONCLUSIONS: Calcification score based on the location and degree of calcifications can predict the increased likelihood of video-assisted thoracoscopic surgery conversion. This scoring system could be one element used to choose the approach for a lobectomy, especially during a surgeon's learning curve.