A direct comparison of robotic and laparoscopic hernia repair: patient-reported outcomes and cost analysis.

PURPOSE: Hernia repair is one of the most commonly performed surgeries in the United States. Since the introduction of the Da Vinci robot, robot-assisted hernia repairs have become more common. In this study we aim to directly compare robotic and laparoscopic hernia repairs as well as explore potential cost differences. We hypothesize that robot-assisted hernia repairs are associated with better patient-reported outcomes. METHODS: We conducted retrospective review to create a cohort study of 53 robotic (37 inguinal and 16 ventral) and 101 laparoscopic (68 inguinal and 33 ventral) hernia repairs. Patient-reported outcomes were measured using the Carolinas Comfort Scale (CCS). Operative details were examined, and a cost analysis was performed. RESULTS: Combining both hernia types together as well as looking at inguinal and ventral repairs separately, we found that there was no difference in hernia recurrence or 1-year CCS between robotic and laparoscopic hernia repair. For ventral hernia repairs alone, robotic procedure was associated with a decreased length of stay. We found that our robotic cases did have longer operative times and higher costs. The operative times did decrease to a length comparable to that of the laparoscopic cases as experience operating with the robot increased. CONCLUSION: In comparison to laparoscopic hernia repair, robotic hernia repair does not improve long-term patient-reported surgical outcomes. However, it does increase the cost of the operation and, in general, result in longer operative times.

Are women benefiting from the Affordable Care Act? A real-world evaluation of the impact of the Affordable Care Act on out-of-pocket costs for contraceptives.

OBJECTIVES: The Affordable Care Act (ACA) mandated that, starting between August 1, 2012 and July 31, 2013, health plans cover most Food and Drug Administration (FDA)-approved contraceptive methods for women without cost sharing. This study examined the impact of the ACA on out-of-pocket expenses for contraceptives. STUDY DESIGN: Women (ages 15-44years) with claims for any contraceptives in years 2011, 2012 and 2013 were identified from the MarketScan Commercial database. The proportions of women using contraceptives [including permanent contraceptives (PCs) and non-PCs: oral contraceptives (OCs), injectables, patches, rings, implants and intrauterine devices (IUDs)] in study years were determined, as well as changes in out-of-pocket expenses for contraceptives during 2011-2013. Demographics, including age, U.S. geographic region of residence and health plan type, were also evaluated. RESULTS: The number of women identified with any contraceptive usage in 2011 was 2,447,316 (mean age: 27.6years), in 2012 was 2,515,296 (mean age: 27.4years) and in 2013 was 2,243,253 (mean age: 27.4years). In 2011, 2012 and 2013, the proportions of women with any contraceptive usage were 26.3%, 26.2% and 26.9%, respectively. Over the three study years, mean total out-of-pocket expenses for PCs and non-PCs decreased from $298 to $82 and from $94 to $30, respectively. For non-PCs, mean total out-of-pocket expenses for OCs and IUDs decreased from $86 to $26 and from $83 to $20. CONCLUSIONS: Implementation of the ACA has saved women a substantial amount in out-of-pocket expenses for contraceptives. IMPLICATIONS: Mean total out-of-pocket expenses for FDA-approved contraceptives decreased approximately 70% from 2011 to 2013. Implementation of the ACA has saved women a substantial amount in out-of-pocket expenses for contraceptives. Longer-term studies, including clinical outcomes, are warranted.

Cost-effectiveness of raloxifene and hormone replacement therapy in postmenopausal women: impact of breast cancer risk.

OBJECTIVE: To examine the life expectancy and cost-effectiveness of hormone replacement therapy (HRT) and raloxifene therapy in healthy 50-year-old postmenopausal women. METHODS: We performed a cost-effectiveness analysis using a Markov model, discounting the value of future costs and benefits to account for their time of occurrence. RESULTS: Both HRT and raloxifene therapy increase life expectancy and are cost-effective relative to no therapy for 50-year-old postmenopausal women. For women at average breast cancer and coronary heart disease risk, lifetime HRT increases quality-adjusted life expectancy more (1.75 versus 1.32 quality-adjusted life years) and costs less ($3802 versus $12,968) than lifetime raloxifene therapy. However, raloxifene is more cost-effective than HRT for women at average coronary risk who have a lifetime breast cancer risk of 15% or higher or who receive 10 years or less of postmenopausal therapy. Raloxifene is also the more cost-effective alternative if HRT reduces coronary heart disease risk by less than 20%. CONCLUSIONS: Assuming the benefit of HRT in coronary heart disease prevention from observational studies, long-term HRT is the most cost-effective alternative for women at average breast cancer and coronary heart disease risk seeking to extend their quality-adjusted life expectancy after menopause. However, raloxifene is the more cost-effective alternative for women at average coronary risk with one or more major breast cancer risk factors (first-degree relative, prior breast biopsy, atypical hyperplasia or BRCA1/2 mutation). These results can help inform decisions about postmenopausal therapy until the results of large scale randomized trials of these therapies become available.

Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegner's granulomatosis undergoing immunosuppressive therapy.

OBJECTIVE: To assess the incremental cost-effectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR. METHODS: A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually. RESULTS: No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased quality-adjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%. CONCLUSION: Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.

Azathioprine for maintenance of remission in Crohn's disease: benefits outweigh the risk of lymphoma.

BACKGROUND & AIMS: Azathioprine is a commonly used and effective treatment for maintenance of remission for patients with steroid-dependent Crohn's disease (CD). However, azathioprine therapy is associated with an increased risk of non-Hodgkin's lymphoma. The objective of this analysis was to determine the impact of azathioprine therapy on survival and quality-adjusted life expectancy after accounting for both the benefits of therapy and potential increased risk of lymphoma. METHODS: A decision analysis using a Markov model depicting the natural history of alternative management strategies for maintenance of remission in patients with CD was performed. RESULTS: In the base-case analysis, treatment of CD patients with a steroid-induced remission with azathioprine resulted in an average increase in life expectancy of 0.04 years and 0.05 quality-adjusted years. The incremental gain in life expectancy decreased with increasing patient age and increasing risk of lymphoma. CONCLUSIONS: Therapy with azathioprine to preserve remission in patients with CD results in increased quality-adjusted life expectancy. This increase was greatest in young patients who have the lowest baseline risk of non-Hodgkin's lymphoma and who have the greatest life expectancy in the absence of a CD-related death.

Overview of the arthritis Cost Consequence Evaluation System (ACCES): a pharmacoeconomic model for celecoxib.

Pharmacoeconomic analyses have become useful and essential tools for health care decision makers who increasingly require such analyses prior to placing a drug on a national, regional or hospital formulary. Previous health economic models of non-steroidal anti-inflammatory drugs (NSAIDs) have been restricted to evaluating a narrow range of agents within specific health care delivery systems using medical information derived from homogeneous clinical trial data. This paper summarizes the Arthritis Cost Consequence Evaluation System (ACCES)--a pharmacoeconomic model that has been developed to predict and evaluate the costs and consequences associated with the use of celecoxib in patients with arthritis, compared with other NSAIDs and NSAIDs plus gastroprotective agents. The advantage of this model is that it can be customized to reflect local practice patterns, resource utilization and costs, as well as provide context-specific health economic information to a variety of providers and/or decision makers.

Cost-effectiveness of MR imaging and core-needle biopsy in the preoperative work-up of suspicious breast lesions.

PURPOSE: To assess the clinical and economic consequences of the use of preoperative breast magnetic resonance (MR) imaging and core-needle biopsy (CNB) to avert excisional biopsy (EXB). MATERIALS AND METHODS: A decision-analytic Markov model was constructed to compare MR imaging, CNB, and EXB without preoperative testing in a woman with a suspicious breast lesion. Stage-specific cancer prevalence, tumor recurrence, progression rates, and MR imaging and CNB sensitivity and specificity were obtained from the literature. Cost estimates were obtained from the literature and from the Medicare fee schedule. RESULTS: EXB without preoperative testing was associated with the greatest quality-adjusted life expectancy, followed by MR imaging and CNB; life expectancies were 17.409, 17.405, and 17.398 years, respectively. EXB resulted in the greatest lifetime treatment cost ($31,438), followed by MR imaging ($29,072) and CNB ($28,573). Results were robust over a wide range of cancer prevalence, stage distribution, tumor progression rates, and procedure and treatment costs. Incremental cost-effectiveness ratios showed that preoperative testing was cost-effective, but the choice between MR imaging and CNB was highly dependent on the accuracy of each test and to patient preferences. CONCLUSION: Preoperative testing of most suspicious breast lesions was cost-effective. More precise estimates of MR imaging and CNB test performance characteristics are needed. Until those are available, patient preferences should inform individual decisions regarding preoperative testing.

Accuracy of MR imaging in the work-up of suspicious breast lesions: a diagnostic meta-analysis.

RATIONALE AND OBJECTIVES: The authors performed a systematic, critical review of the literature on magnetic resonance (MR) imaging for primary breast cancer detection in patients with suspicious breast lesions, analyzed MR test performance in the articles meeting study criteria, and used this information to examine the cost-effectiveness of preoperative MR imaging. MATERIALS AND METHODS: A structured, predefined MEDLINE search was conducted to identify potentially relevant, peer-reviewed, English-language references from January 1996 through August 1997 on the diagnostic accuracy of breast MR imaging. This information was supplemented by manually searching bibliographies of the retrieved articles for additional potentially relevant references. All studies were independently abstracted by two reviewers using a prospectively designed worksheet. Abstraction results were analyzed with the summary receiver operating characteristic (ROC) method. RESULTS: Of 41 identified studies, 16 met the inclusion criteria. These studies reported sensitivities ranging from 63% to 100% and specificities ranging from 21% to 100%. Maximum joint sensitivity and specificity of the summary ROC curve was 89% (95% confidence interval [CI]: 82%, 93%). At a sensitivity of 95%, specificity was 67%. When test performance values were applied to a previous cost-effectiveness analysis, the cost-effectiveness of preoperative MR imaging relative to that of excisional biopsy was confirmed, but its cost-effectiveness relative to that of needle core biopsy varied widely. CONCLUSION: For MR imaging to be a cost-effective alternative to excisional biopsy for diagnosis of suspicious breast lesions, its diagnostic test performance must be equal to or better than the best results in recently published studies.

Antibiotic therapy of Helicobacter pylori infection reduces healthcare expenditures related to duodenal ulcer.

OBJECTIVE: To test whether eradication of Helicobacter pylori saves costs in the treatment of duodenal ulcer disease, compared with conventional antisecretory therapy. STUDY DESIGN: A prospective, double-blind clinical trial was conducted at 132 sites in the United States. PATIENTS AND METHODS: Adult patients with active duodenal ulcer and confirmed H pylori infection were randomized to receive treatment with clarithromycin plus omeprazole, omeprazole alone, or ranitidine alone. Utilization of ulcer-related healthcare resources was documented during 1 year following therapy. Costs were calculated by multiplying the number of health resources utilized by the cost of each resource. Resource costs were obtained from a database containing actual average costs spent by managed care organizations on outpatient and inpatient treatment. RESULTS: Of the 819 patients enrolled, 727 completed the study: 243 received clarithromycin plus omeprazole, 248 omeprazole alone, and 236 ranitidine alone. Ulcer-related health resource utilization and total ulcer-related healthcare costs were decreased after treatment with clarithromycin plus omeprazole, compared to treatment with omeprazole or ranitidine alone. In multivariate linear regression analyses, type of treatment was found to be a significant predictor of total costs. Specific costs associated with endoscopic examinations, clinic visits, and medications were also significantly reduced by treatment with clarithromycin plus omeprazole as compared to other treatment forms. CONCLUSIONS: In a managed care environment, therapy with clarithromycin and omeprazole to eradicate H pylori in patients with duodenal ulcer disease would result in significant cost savings secondary to a reduction in the utilization of healthcare resources.

Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.

CONTEXT: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. OBJECTIVE: To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. DESIGN: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. SETTING: Two urban, academically affiliated hospitals in Philadelphia, Pa. PARTICIPANTS: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. INTERVENTION: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. MAIN OUTCOME MEASURES: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. RESULTS: A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction. CONCLUSIONS: An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs.

Screening for urinary tract infection in infants in the emergency department: which test is best?

OBJECTIVE: Comparison of rapid tests and screening strategies for detecting urinary tract infection (UTI) in infants. METHODS: Cross-sectional study conducted in an urban tertiary care children's hospital emergency department and clinical laboratories of 3873 infants <2 years of age who had a urine culture obtained in the emergency department by urethral catheterization; results of urine dipstick tests for leukocyte esterase or nitrites, enhanced urinalysis (UA) (urine white blood cell count/mm3 plus Gram stain), Gram stain alone, and dipstick plus microscopic UA (white blood cells and bacteria per high-powered field) compared with urine culture results (positive urine results defined as >/=10 colony-forming units per milliliter of urinary tract pathogen) for each sample. Cost comparison of 1) dipstick plus culture of all urine specimens versus 2) cell count +/- Gram stain of urine, culture only those with positive results. RESULTS: The enhanced UA was most sensitive at detecting UTI (94%; 95% confidence interval: 83,99), but had more false-positive results (16%) than the urine dipstick or Gram stain (3%). The most cost-effective strategy was to perform cultures on all infants and begin presumptive treatment on those whose dipstick had at least moderate (+2) leukocyte esterase or positive nitrite at a cost of $3.70 per child. With this strategy, all infants with UTI were detected. If the enhanced UA was used to screen for when to send the urine for culture, 82% of cultures would be eliminated, but 4% to 6% of infants with UTI would be missed and the cost would be higher ($6.66 per child). CONCLUSION: No rapid test can detect all infants with UTI. Physicians should send urine for culture from all infants and begin presumptive treatment only on those with a significantly positive dipstick result. The enhanced UA is most sensitive for detecting UTI, but is less specific and more costly, and should be reserved for the neonate for whom a UTI should not be missed at first visit.

Cost savings in duodenal ulcer therapy through Helicobacter pylori eradication compared with conventional therapies: results of a randomized, double-blind, multicenter trial. Gastrointestinal Utilization Trial Study Group.

BACKGROUND: We hypothesized that treatment of duodenal ulcer disease with antibiotic therapy directed toward Helicobacter pylori infection is more cost-effective than therapy with antisecretory agents. METHODS: A randomized, double-blind, multicenter clinical trial of adult patients with active duodenal ulcer and H. pylori infection was conducted. Patients were randomized to receive 500 mg of clarithromycin 3 times a day plus 40 mg of omeprazole daily for 14 days followed by 20 mg of omeprazole daily for an additional 14 days (group 1), 20 mg of omeprazole daily for 28 days (group 2), or 150 mg of ranitidine hydrochloride twice a day for 28 days (group 3). The use of ulcer-related health care resources was documented during monthly interviews for 1 year after the initial therapy. Clinical success was evaluated 4 to 6 weeks and 1 year after the end of therapy. RESULTS: Of the 819 patients enrolled, 727 completed the study. Group 1 included 243 patients; group 2, 248 patients; and group 3, 236 patients. Patients in group 1 used fewer ulcer-related health care resources during the 1 year after therapy compared with groups 2 and 3 (comparisons are given as group 1 vs group 2 and group 1 vs group 3, respectively): the number of endoscopies performed, 28 vs 76 (P<.001) and vs 71 (P<.001); patients receiving drugs to treat an ulcer, 118 vs 180 (P<.001) and vs 168 (P<.001); clinic visits, 83 vs 135 (P=.05) and vs 161 (P<.001); hospitalizations, 0 vs 5 (P=.045) and vs 6 (P=.02); and length of hospital stay, 0 vs 24 days (P=.04) and vs 37 (P=.04). When ulcer-related costs were defined as the outcome variable in a multivariate linear regression analysis, therapy was determined to have a significant influence on costs (group 1 vs group 2, P<.001; group 1 vs group 3, P=.008). Clinical success rates at the end of the study and cure of H. pylori infection were significantly greater in group 1 compared with groups 2 and 3 (P<.001). Therapy with clarithromycin plus omeprazole provided savings of $1.94 and $2.96 (compared with therapy with omeprazole and with ranitidine hydrochloride, respectively) per dollar spent within the first year after therapy. This incremental cost-benefit translates to savings of $547 or $835 per patient in group 1 (compared with patients in group 2 or group 3, respectively) during the first year after therapy. CONCLUSIONS: Combination therapy with clarithromycin and omeprazole resulted in significantly fewer uses of ulcer-related health care resources than conventional antisecretory therapy during a 1-year follow-up and significant savings in associated costs during the same period. Patients who received clarithromycin plus omeprazole also showed a significantly improved clinical outcome compared with patients who received only omeprazole or ranitidine.

Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras.

PURPOSE: Examine changing patient characteristics and surgical outcomes for patients undergoing cholecystectomy at five community hospitals in 1989 and 1993. PROCEDURES: In a retrospective chart review, data were gathered regarding gallstone disease severity, type of admission, patient age, number of comorbidities, American Society of Anesthesiologists (ASA) Physical Status Classification, length of stay, and multiple outcomes of surgery. MAIN FINDINGS: The volume of nonincidental cholecystectomies increased 26%, from 1611 in 1989 to 2031 in 1993. Nearly all of the increase occurred among patients with uncomplicated cholelithiasis and with elective admissions. In 1993, lengths of stay were significantly shorter and percentages of complications were significantly lower for infectious, cardiac, pulmonary, and gastrointestinal complications when controlling for patient case-mix characteristics. There were more major intraoperative complications (unintended wounds or injuries to the common bile duct, bowel, blood vessel(s), or other organs) in 1993. CONCLUSIONS: Different types of patients underwent cholecystectomy in 1993 compared with patients in 1989, which supports the hypothesis of changing thresholds. Statements supporting the safety of cholecystectomy in the laparoscopic era were borne out when controlling for differences in patient characteristics.

Incremental cost of department-wide implementation of a picture archiving and communication system and computed radiography.

PURPOSE: To determine the incremental cash flows associated with department-wide implementation of a picture archiving and communication system (PACS) and computed radiography (CR) at a large academic medical center. MATERIALS AND METHODS: The authors determined all capital and operational costs associated with PACS implementation during an 8-year time horizon. Economic effects were identified, adjusted for time value, and used to calculate net present values (NPVs) for each section of the department of radiology and for the department as a whole. RESULTS: The chest-bone section used the most resources. Changes in cost assumptions for the chest-bone section had a dominant effect on the department-wide NPV. The base-case NPV (i.e., that determined by using the initial assumptions) was negative, indicating that additional net costs are incurred by the radiology department from PACS implementation. PACS and CR provide cost savings only when a 12-year hardware life span is assumed, when CR equipment is removed from the analysis, or when digitized long-term archives are compressed at a rate of 10:1. CONCLUSION: Full PACS-CR implementation would not provide cost savings for a large, subspecialized department. However, institutions that are committed to CR implementation (for whom CR implementation would represent a sunk cost) or institutions that are able to archive images by using image compression will experience cost savings from PACS.

Epidemiology of sepsis syndrome in 8 academic medical centers.

CONTEXT: Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population. OBJECTIVE: To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting. DESIGN: Prospective, multi-institutional, observational study including 5-month follow-up. SETTING: Eight academic tertiary care centers. METHODS: Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-ICU patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction. RESULTS: From January 4, 1993, to April 2, 1994, 12759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean+/-95% confidence limit) of sepsis syndrome was 2.0+/-0.16 cases per 100 admissions, or 2.8+/-0.17 per 1000 patient-days. The unadjusted attack rate for sepsis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11%, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months. CONCLUSIONS: Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available.

The relationship between choice of outcome measure and hospital rank in general surgical procedures: implications for quality assessment.

OBJECTIVE: Institutional complication rates are often used to assess hospital quality of care, particularly for conditions and procedures where mortality rates are not useful because deaths are rare. The objective of this study was to assess the correlation among hospital quality assessment rankings based on adjusted mortality, complication and failure-to-rescue rates. DESIGN: This study used a clinically detailed administrative data set to compare severity and case-mix adjusted hospital outcome rankings for three different measures of quality of care: in-hospital death, complication and failure-to-rescue (in-hospital death following a complication). SETTING AND PATIENTS: Analysis of 74,647 patients who underwent general surgical procedures included in the 1991 and 1992 MedisGroups National Comparative Data Base. MEASUREMENTS: Adjusted outcomes of death, complication and failure to rescue based on multivariable logistic regression models. RESULTS: For 142 hospitals, the correlation between hospital rankings based on the death rate and those ranked by the complication rate was only 0.208 (P = 0.013). A similarly low correlation was present between the complication and failure rate rankings, r = -0.090 (P = 0.287). A higher correlation was observed between the death and failure rate rankings, r = 0.90 (P < 0.001). CONCLUSIONS: For general surgical procedures, hospital rank using the complication rate is poorly correlated with rankings using the death or failure rate. Complication rates should be used with great caution and should not be used in isolation when assessing hospital quality of care.