RESUMEN
OBJECTIVE: The aim of this study was to investigate whether the Hospital Readmissions Reduction Program, a national program that introduced financial penalties for high readmission rates for certain medical conditions, had a "spillover" effect on surgical conditions. SUMMARY BACKGROUND DATA: During the past decade, there have been multiple national efforts to improve surgical care. Readmission rates are a key metric for assessing surgical quality. Whether surgical readmission rates have declined, and whether the Hospital Readmissions Reduction Program has had an influence is unclear. METHODS: Using national Medicare data, we identified patients undergoing a range of procedures during the past decade. We examined whether certain procedures that would be targeted by the HRRP had a differential change in readmissions compared to other procedures. We used an interrupted time-series model to examine readmission trends in three time periods: pre-ACA, HRRP implementation, and HRRP penalty. RESULTS: Between 2005 and 2014, 17,423,106 patients underwent the procedures of interest; risk-adjusted rates of readmission across the 8 procedures declined from 12.2% to 8.6%. Pre-ACA rates of readmission were decreasing [-0.060% per quarter (-0.072%, -0.048%), P < 0.001]. During the HRRP implementation period, the rate of decline of readmissions increased [-0.129% (-0.142%, -0.116%), P < 0.001] and continued declining at a similar rate during the penalty period [-0.118% (-0.131%, -0.105%), P < 0.001]. Largest declines in surgical readmissions were seen among the nontargeted procedures. The hospitals with the greatest reductions in medical readmissions also had the greatest drop in surgical readmissions. CONCLUSIONS: Surgical readmission rates have fallen during the past decade and rates of decline have increased during the HRRP period.
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Readmisión del Paciente/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/normas , Hospitalización , Humanos , Medicare , Readmisión del Paciente/economía , Readmisión del Paciente/tendencias , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad , Estados UnidosRESUMEN
BACKGROUND: There is no consensus on the use of chest imaging in pancreatic ductal adenocarcinoma (PDAC) patients. Among PDAC patients, we examined the use of chest computed tomography (CT) over time and determined whether the use of chest CT led to a survival difference or change in management via identification of indeterminate lung nodules (ILNs). METHODS: Retrospective clinical data was collected for patients diagnosed with PDAC from 1998 to 2014. We examined the proportion of patients undergoing staging chest CT scan and those who had ILN, defined as ≥ 1 well-defined, noncalcified lung nodule(s) ≤ 1 cm in diameter. We determined time to overall survival (OS) using multivariate Cox regression. We also assessed changes in management of PDAC patients who later developed lung metastasis only. RESULTS: Of the 2710 patients diagnosed with PDAC, 632 (23%) had greater than one chest CT. Of those patients, 451 (71%) patients had ILNs, whereas 181 (29%) had no ILNs. There was no difference in median overall survival in patients without ILNs (16.4 [13.6, 19.0] months) versus those with ILN (14.8 [13.6, 15.8] months, P = 0.18). Examining patients who developed isolated lung metastases (3.3%), we found that staging chest CTs did not lead to changes in management of the primary abdominal tumor. CONCLUSIONS: Survival did not differ for PDAC patients with ILNs identified on staging chest CTs compared with those without ILNs. Furthermore, ILN identification did not lead to changes in management of the primary abdominal tumor, questioning the utility of staging chest CTs for PDAC patients.
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Carcinoma Ductal Pancreático/diagnóstico por imagen , Neoplasias Pulmonares/diagnóstico por imagen , Nódulos Pulmonares Múltiples/diagnóstico por imagen , Neoplasias Pancreáticas/patología , Anciano , Carcinoma Ductal Pancreático/secundario , Carcinoma Ductal Pancreático/terapia , Toma de Decisiones Clínicas , Femenino , Humanos , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Nódulos Pulmonares Múltiples/secundario , Estadificación de Neoplasias , Neoplasias Pancreáticas/terapia , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Tasa de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To assess if an incongruous increase in mortality occurs after postoperative day 30. BACKGROUND: In the current climate of public reporting and pay-for-performance, 30-day mortality after inpatient surgery has become a key metric to assess performance. Whereas the intent is to improve quality, there has been increasing concern that reporting 30-day mortality may influence providers' timing of treatment withdrawal. METHODS: We used national Medicare data to identify beneficiaries who underwent 1 of 19 major surgical procedures. We performed a survival analysis and calculated an adjusted daily hazard rate using all-cause mortality, accounting for patient comorbidities and case-mix. We ran linear regression models to examine discontinuity points around the 30-day mark, and conducted subgroup analyses for hospitals participating in the National Surgical Quality Improvement Program, which focuses on 30-day mortality reporting. RESULTS: We identified 872,968 patients who underwent 1 of 19 surgical procedures of interest; 71,583 of these patients (8.2%) died within 60 days of their index operation. We did not observe any statistically significant increases in mortality in the immediate period after day 30 compared with the immediate period before day 30. In fact, in each model, mortality rates tended to fall in the days after day 30, consistent with a general decreasing risk of death over time. These findings were similar among National Surgical Quality Improvement Program hospitals. CONCLUSIONS: We found no evidence of an increase in postoperative mortality after day 30. As payers move towards incorporating 30-day surgical mortality into pay-for-performance programs, these findings serve as a benchmark for measuring potential future unintended consequences of the metric.
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Mortalidad Hospitalaria , Hospitales/normas , Mejoramiento de la Calidad , Anciano , Femenino , Humanos , Modelos Lineales , Masculino , Medicare , Análisis de Supervivencia , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To investigate the effect of subspecialty practice and experience on the relationship between annual volume and inpatient mortality after hepatic resection. BACKGROUND: The impact of annual surgical volume on postoperative outcomes has been extensively examined. However, the impact of cumulative surgeon experience and specialty training on this relationship warrants investigation. METHODS: The New York Statewide Planning and Research Cooperative System inpatient database was queried for patients' ≥18 years who underwent wedge hepatectomy or lobectomy from 2000 to 2014. Primary exposures included annual surgeon volume, surgeon experience (early vs late career), and surgical specialization-categorized as general surgery (GS), surgical oncology (SO), and transplant (TS). Primary endpoint was inpatient mortality. Hierarchical logistic regression was performed accounting for correlation at the level of the surgeon and the hospital, and adjusting for patient demographics, comorbidities, presence of cirrhosis, and annual surgical hospital volume. RESULTS: A total of 13,467 cases were analyzed. Overall inpatient mortality was 2.35%. On unadjusted analysis, late career surgeons had a mortality rate of 2.62% versus 1.97% for early career surgeons. GS had a mortality rate of 2.98% compared with 1.68% for SO and 2.67% for TS. Once risk-adjusted, annual volume was associated with reduced mortality only among early-career surgeons (odds ratio 0.82, P = 0.001) and general surgeons (odds ratio 0.65, P = 0.002). No volume effect was seen among late-career or specialty-trained surgeons. CONCLUSIONS: Annual volume alone likely contributes only a partial assessment of the volume-outcome relationship. In patients undergoing hepatic resection, increased annual volume did not confer a mortality benefit on subspecialty surgeons or late career surgeons.
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Competencia Clínica , Hepatectomía/mortalidad , Hepatectomía/estadística & datos numéricos , Mortalidad Hospitalaria , Complicaciones Posoperatorias/mortalidad , Especialización , Femenino , Hepatectomía/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , New York/epidemiología , Evaluación de Resultado en la Atención de SaludRESUMEN
BACKGROUND: Recent advances in imaging and the increasing use of neoadjuvant therapy puts the contemporary utility of staging laparoscopy for patients with pancreatic adenocarcinoma (PDAC) into question. This study aimed to develop a prognostic score to optimize prevention of an unnecessary laparotomy and minimize the rate for unnecessary laparoscopy. METHODS: Clinicopathologic data were evaluated for all patients undergoing surgical intervention for PDAC between 2001 and 2015, who were stratified into group 1 (2001-2008) and group 2 (2009-2014). RESULTS: The study identified 1001 patients eligible for analysis, 331 (33%) of whom underwent a staging laparoscopy before exploration. An unnecessary laparotomy was prevented for 44.4% of the patients in period 1 and for 24% of the patients in period 2 (p < 0.001). Male gender [odds ratio (OR), 1.8; p < 0.05], preoperative resectability (borderline resectable OR 2.1; p < 0.019; locally advanced OR 7.6; p < 0.001), CA 19-9 levels higher than 394 U/L (OR 3.1; p < 0.001), no neoadjuvant chemotherapy (OR 2.7; p = 0.012), and pancreatic body or tail lesions (OR 1.8; p = 0.063) were predictive of occult metastatic disease. The developed scoring index demonstrated a c-statistic of 0.729. The observed-to-expected ratio for the index at every score level validated the index's model. A score cutoff at 4 was able to detect 76.1% of radiographically occult metastatic disease. CONCLUSION: The rate for unnecessary laparotomy among patients with PDAC has decreased in contemporary times, but unnecessary laparotomy still occurs for 1 in 4 patients. Using our scoring system, a cutoff of 4 allows 76% of radiographically occult metastases to be predicted, thereby selecting high-risk patients for laparoscopic biopsy and potentially avoiding a non-therapeutic laparotomy.
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Adenocarcinoma/secundario , Laparoscopía/métodos , Neoplasias Pancreáticas/patología , Adenocarcinoma/cirugía , Anciano , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Pancreáticas/cirugía , Neoplasias PancreáticasAsunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Unidades de Observación Clínica/tendencias , Utilización de Instalaciones y Servicios/tendencias , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/tendencias , Readmisión del Paciente/tendencias , Negro o Afroamericano , Cuidados Posteriores/métodos , Cuidados Posteriores/normas , Cuidados Posteriores/tendencias , Anciano , Anciano de 80 o más Años , Unidades de Observación Clínica/normas , Utilización de Instalaciones y Servicios/normas , Femenino , Disparidades en el Estado de Salud , Humanos , Masculino , Medicare/tendencias , Readmisión del Paciente/normas , Pautas de la Práctica en Medicina/tendencias , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Estudios Retrospectivos , Estados Unidos , Población BlancaAsunto(s)
Betacoronavirus , Infecciones por Coronavirus , Becas , Entrevistas como Asunto/métodos , Pandemias , Neumonía Viral , Comunicación por Videoconferencia , COVID-19 , Docentes Médicos/organización & administración , Humanos , Entrevistas como Asunto/normas , Selección de Personal , SARS-CoV-2RESUMEN
Introduction: Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. Results: We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p < 0.001); NHB race had more effect in patients <65 years old (HR 1.44, 95% CI 1.39-1.49, p < 0.001) than in those ≥65 (HR 1.13, 95% CI 1.11-1.15, p < 0.001). In the VA, age stratification was not significant (p = 0.21). Discussion: Racial disparities in CRC survival in the general US population are significantly attenuated in Medicare-aged patients. This pattern is not present in the VA, suggesting that access to care may be an important component of racial disparities in this disease.
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Negro o Afroamericano , Neoplasias Colorrectales , Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud , Programa de VERF , Población Blanca , Humanos , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/etnología , Masculino , Femenino , Estados Unidos/epidemiología , Anciano , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Persona de Mediana Edad , Disparidades en Atención de Salud/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Estudios de Cohortes , Análisis de Supervivencia , Anciano de 80 o más Años , United States Department of Veterans Affairs/estadística & datos numéricos , AdultoRESUMEN
IMPORTANCE: Patients 80 years and older with pancreatic ductal adenocarcinoma (PDAC) have not consistently received treatments that have established benefits in younger older adults (aged 60-79 years), yet patients 80 years and older are increasingly being offered surgery. Whether adjuvant chemotherapy (AC) provides additional benefit among patients 80 years and older with PDAC following surgery is not well understood. OBJECTIVE: To describe patterns of AC use in patients 80 years and older following surgical resection of PDAC and to compare overall survival between patients who received AC and those who did not. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study among patients 80 years or older diagnosed with PDAC (stage I-III) between 2004 to 2016 who underwent a pancreaticoduodenectomy at hospitals across the US reporting to the National Cancer Database. EXPOSURES: AC vs no AC 90 days following diagnosis of PDAC. MAIN OUTCOMES AND MEASURES: The proportion of patients who received AC was assessed over the study period. Overall survival was compared between patients who received AC and those who did not using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. A landmark analysis was performed to address immortal time bias. A propensity score analysis was performed to address indication bias. Subgroup analyses were conducted in node-negative, margin-negative, clinically complex, node-positive, and margin-positive cohorts. RESULTS: Between 2004 and 2016, 2569 patients 80 years and older (median [IQR] age, 82 [81-84] years; 1427 were women [55.5%]) underwent surgery for PDAC. Of these patients, 1217 (47.4%) received AC. Findings showed an 18.6% (95% CI, 8.0%-29.0%; P = .001) absolute increase in the use of AC among older adults who underwent a pancreaticoduodenectomy comparing rates in 2004 vs 2016. Receipt of AC was associated with a longer median survival (17.2 months; 95% CI, 16.1-19.0) compared with those who did not receive AC (12.7 months; 95% CI, 11.8-13.6). This association was consistent in propensity and subgroup analyses. In multivariable analysis, receipt of AC (hazard ratio [HR], 0.72; 95% CI, 0.65-0.79; P < .001), female sex (HR, 0.88; 95% CI, 0.80-0.96; P < .001), and surgery in the more recent time period (≥2011) (HR, 0.90; 95% CI, 0.82-0.99; P = .02) were associated with a decreased hazard of death. An increased hazard of death was associated with higher pathologic stage (stage II: HR, 1.68; 95% CI, 1.43-1.97; P < .001; stage III: HR, 2.39; 95% CI, 1.88-3.04; P < .001), positive surgical margins (HR, 1.49; 95% CI, 1.34-1.65; P < .001), length of stay greater than median (10 days) (HR, 1.17; 95% CI, 1.07-1.28; P < .001), and receipt of oncologic care at a nonacademic facilities (Community Cancer Program: HR, 1.20; 95% CI, 1.07-1.35; P < .001; Integrated Network Cancer Program: HR, 1.25; 95% CI, 1.07-1.46; P < .001). CONCLUSIONS AND RELEVANCE: In this cohort study, the use of AC among patients who underwent resection for PDAC increased over the study period, yet it still was administered to fewer than 50% of patients. Receipt of AC was associated with a longer median survival.
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Adenocarcinoma , Neoplasias Pancreáticas , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/cirugía , Anciano , Anciano de 80 o más Años , Quimioterapia Adyuvante , Estudios de Cohortes , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Pancreáticas/tratamiento farmacológico , Neoplasias Pancreáticas/cirugía , Estudios RetrospectivosRESUMEN
OBJECTIVES: To compare patterns of technological adoption of minimally invasive surgery for radical prostatectomy across the United States and England. DATA SOURCES: We examine radical prostatectomy in the United States and England between 2005 and 2017, using de-identified administrative claims data from the OptumLabs Data Warehouse in the United States and the Hospital Episodes Statistics in England. STUDY DESIGN: We conducted a longitudinal analysis of robotic, laparoscopic, and open surgery for radical prostatectomy. We compared the trends of adoption over time within and across countries. Next, we explored whether differential adoption patterns in the two health systems are associated with differences in volumes and patient characteristics. Finally, we explored the relationship between these adoption patterns and length of stay, 30-day readmission, and urology follow-up visits. DATA COLLECTION: Open, laparoscopic, and robotic radical prostatectomies are identified using Office of Population Censuses and Surveys Classification of Interventions and Procedures (OPCS) codes in England and International Classification of Diseases ninth revision (ICD9), ICD10, and Current Procedural Terminology (CPT) codes in the United States. PRINCIPAL FINDINGS: We identified 66,879 radical prostatectomies in England and 79,358 in the United States during 2005-2017. In both countries, open surgery dominates until 2009, where it is overtaken by minimally invasive surgery. The adoption of robotic surgery is faster in the United States. The adoption rates and, as a result, the observed centralization of volume, have been different across countries. In both countries, patients undergoing radical prostatectomies are older and have more comorbidities. Minimally invasive techniques show decreased length of stay and 30-day readmissions compared to open surgery. In the United States, robotic approaches were associated with lower length of stay and readmissions when compared to laparoscopic. CONCLUSIONS: Robotic surgery has become the standard approach for radical proctectomy in the United States and England, showing decreased length of stay and in 30-day readmissions compared to open surgery. Adoption rates and specialization differ across countries, likely a product of differences in cost-containment efforts.
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Revisión de Utilización de Seguros , Tiempo de Internación/estadística & datos numéricos , Prostatectomía/estadística & datos numéricos , Neoplasias de la Próstata/cirugía , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Anciano , Inglaterra , Hospitales/estadística & datos numéricos , Humanos , Laparoscopía , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Estados UnidosRESUMEN
The United States currently has one of the highest numbers of cumulative COVID-19 cases globally, and Latino and Black communities have been disproportionately affected. Understanding the community-level factors that contribute to disparities in COVID-19 case and death rates is critical to developing public health and policy strategies. We performed a cross-sectional analysis of U.S. counties and found that a 10% point increase in the Black population was associated with 324.7 additional COVID-19 cases per 100,000 population and 14.5 additional COVID-19 deaths per 100,000. In addition, we found that a 10% point increase in the Latino population was associated with 293.5 additional COVID-19 cases per 100,000 and 7.6 additional COVID-19 deaths per 100,000. Independent predictors of higher COVID-19 case rates included average household size, the share of individuals with less than a high school diploma, and the percentage of foreign-born non-citizens. In addition, average household size, the share of individuals with less than a high school diploma, and the proportion of workers that commute using public transportation independently predicted higher COVID-19 death rates within a community. After adjustment for these variables, the association between the Latino population and COVID-19 cases and deaths was attenuated while the association between the Black population and COVID-19 cases and deaths largely persisted. Policy efforts must seek to address the drivers identified in this study in order to mitigate disparities in COVID-19 cases and deaths across minority communities.
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COVID-19/diagnóstico , Participación de la Comunidad/métodos , Mortalidad/etnología , Grupos Raciales/estadística & datos numéricos , COVID-19/epidemiología , COVID-19/mortalidad , Participación de la Comunidad/estadística & datos numéricos , Estudios Transversales , Humanos , Mortalidad/tendencias , Grupos Raciales/etnología , Estados Unidos/epidemiología , Estados Unidos/etnologíaAsunto(s)
Quistes/complicaciones , Ictericia Obstructiva/etiología , Hepatopatías/complicaciones , Anciano , Colangiopancreatografia Retrógrada Endoscópica , Quistes/diagnóstico , Quistes/cirugía , Humanos , Ictericia Obstructiva/diagnóstico , Ictericia Obstructiva/cirugía , Hepatopatías/diagnóstico , Hepatopatías/cirugía , Pruebas de Función Hepática , Imagen por Resonancia Magnética , Masculino , Stents , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Importance: Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time. Objective: To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers. Design, Setting, and Participants: In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer. Exposures: Cancer surgery among Black and White patients. Main Outcomes and Measures: Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery. Results: A total of 870â¯929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103â¯446 patients had cancer operations (96â¯210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44). Conclusions and Relevance: These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.
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Negro o Afroamericano/estadística & datos numéricos , Oncología Médica/tendencias , Neoplasias/mortalidad , Procedimientos Quirúrgicos Operativos/mortalidad , Población Blanca/estadística & datos numéricos , Anciano , Estudios Transversales , Bases de Datos Factuales , Femenino , Disparidades en Atención de Salud , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Medicare , Persona de Mediana Edad , Neoplasias/etnología , Neoplasias/cirugía , Periodo Posoperatorio , Estados Unidos/epidemiologíaRESUMEN
This Viewpoint describes a circular economy for operating room supply chain networks as a climate-oriented approach that maintains organizational viability and patient health and welfare.
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Cambio Climático , Conservación de los Recursos NaturalesRESUMEN
OBJECTIVE: To investigate whether patients' mortality differs according to the age and sex of surgeons. DESIGN: Observational study. SETTING: US acute care hospitals. PARTICIPANTS: 100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014. MAIN OUTCOME MEASURE: Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals. RESULTS: 892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality. CONCLUSION: Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.
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Competencia Clínica/estadística & datos numéricos , Competencia Clínica/normas , Cirugía General/normas , Complicaciones Posoperatorias/mortalidad , Calidad de la Atención de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/normas , Cirujanos/estadística & datos numéricos , Cirujanos/normas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Investigación sobre Servicios de Salud , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Pautas de la Práctica en Medicina , Factores Sexuales , Estados UnidosAsunto(s)
Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía , Adenocarcinoma/patología , Antígeno CA-19-9/sangre , Quimioterapia Adyuvante , Humanos , Ganglios Linfáticos/patología , Márgenes de Escisión , Terapia Neoadyuvante , Clasificación del Tumor , Neoplasias Pancreáticas/patología , Calidad de Vida , Radioterapia Adyuvante , Tasa de SupervivenciaRESUMEN
Catastrophic medical malpractice payouts, $1 million or greater, greatly influence physicians' practice, hospital policy, and discussions of healthcare reform. However, little is known about the specific characteristics and overall cost burden of these payouts. We reviewed all paid malpractice claims nationwide using the National Practitioner Data Bank over a 7-year period (2004-2010) and used multivariate regression to identify risk factors for catastrophic and increased overall payouts. Claims with catastrophic payouts represented 7.9% (6,130/77,621) of all paid claims. Factors most associated with catastrophic payouts were patient age less than 1 year; quadriplegia, brain damage, or lifelong care; and anesthesia allegation group. Compared with court judgments, settlement was associated with decreased odds of a catastrophic payout (odds ratio, 0.31; 95% confidence interval [CI], 0.22-0.42) and lower estimated average payouts ($124,863; 95% CI, $101,509-144,992). A physician's years in practice and previous paid claims history had no effect on the odds of a catastrophic payout. Catastrophic payouts averaged $1.4 billion per year or 0.05% of the National Health Expenditures. Preventing catastrophic malpractice payouts should be only one aspect of comprehensive patient safety and quality improvement strategies. Future studies should evaluate the benefits of targeted interventions based on specific patient safety event characteristics.
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Jurisprudencia , Mala Praxis/economía , Mala Praxis/estadística & datos numéricos , Factores de Edad , Anestesia/efectos adversos , Anestesia/economía , Daño Encefálico Crónico/economía , Humanos , Responsabilidad Legal , Médicos , Cuadriplejía/economía , Factores de Riesgo , Estados UnidosRESUMEN
BACKGROUND: Surgical never events are being used increasingly as quality metrics in health care in the United States. However, little is known about their costs to the health care system, the outcomes of patients, or the characteristics of the providers involved. We designed a study to describe the number and magnitude of paid malpractice claims for surgical never events, as well as associated patient and provider characteristics. METHODS: We used the National Practitioner Data Bank, a federal repository of medical malpractice claims, to identify malpractice settlements and judgments of surgical never events, including retained foreign bodies, wrong-site, wrong-patient, and wrong-procedure surgery. Payment amounts, patient outcomes, and provider characteristics were evaluated. RESULTS: We identified a total of 9,744 paid malpractice settlement and judgments for surgical never events occurring between 1990 and 2010. Malpractice payments for surgical never events totaled $1.3 billion. Mortality occurred in 6.6% of patients, permanent injury in 32.9%, and temporary injury in 59.2%. Based on literature rates of surgical adverse events resulting in paid malpractice claims, we estimated that 4,082 surgical never event claims occur each year in the United States. Increased payments were associated with severe patient outcomes and claims involving a physician with multiple malpractice reports. Of physicians named in a surgical never event claim, 12.4% were later named in at least 1 future surgical never event claim. CONCLUSION: Surgical never events are costly to the health care system and are associated with serious harm to patients. Patient and provider characteristics may help to guide prevention strategies.