Evaluation of sex differences in the receipt of concomitant atrial fibrillation procedures during nonmitral cardiac surgery.

OBJECTIVE: Women are less likely to receive guideline-recommended cardiovascular care, but evaluation of sex-based disparities in cardiac surgical procedures is limited. Receipt of concomitant atrial fibrillation (AF) procedures during nonmitral cardiac surgery was compared by sex for patients with preoperative AF. METHODS: Patients with preoperative AF undergoing coronary artery bypass grafting and/or aortic valve replacement at any of the 33 hospitals in Michigan from 2014 to 2022 were included. Patients with prior cardiac surgery, transcatheter AF procedure, or emergency/salvage status were excluded. Hierarchical logistic regression identified predictors of concomitant AF procedures, account for hospital and surgeon as random effects. RESULTS: Of 5460 patients with preoperative AF undergoing nonmitral cardiac surgery, 24% (n = 1291) were women with a mean age of 71 years. Women were more likely to have paroxysmal (vs persistent) AF than men (80% vs 72%; P < .001) and had a higher mean predicted risk of mortality (5% vs 3%; P < .001). The unadjusted rate of concomitant AF procedure was 59% for women and 67% for men (P < .001). After risk adjustment, women had 26% lower adjusted odds of concomitant AF procedure than men (adjusted odds ratio, 0.74; 95% CI, 0.64-0.86; P < .001). Female sex was the risk factor associated with the lowest odds of concomitant AF procedure. CONCLUSIONS: Women are less likely to receive guideline recommended concomitant AF procedure during nonmitral surgery. Identification of barriers to concomitant AF procedure in women may improve treatment of AF.

Home Health Care Use and Outcomes After Coronary Artery Bypass Grafting Among Medicare Beneficiaries.

BACKGROUND: Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. METHODS: Retrospective analysis of 100% of Medicare fee-for-service files identified 77 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. RESULTS: A total of 26 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. CONCLUSIONS: A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries.

OBJECTIVE: Despite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes. METHODS: This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use. RESULTS: Overall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001). CONCLUSIONS: Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

The relationship between discharge location and cardiac rehabilitation use after cardiac surgery.

BACKGROUND: Cardiac rehabilitation (CR) is a guideline-recommended risk-reduction program offered to cardiac surgical patients. Despite CR's association with better outcomes, attendance remains poor. The relationship between discharge location and CR use is poorly understood. METHODS: This study was a nationwide, retrospective cohort analysis of Medicare fee-for-service claims for beneficiaries undergoing coronary artery bypass grafting and/or surgical aortic valve repair between July 1, 2016, and December 31, 2018. The primary outcome was attendance of any CR session. Discharge location was categorized as home discharge or discharge to extended care facility (ECF) (including skilled nursing facility, inpatient rehabilitation, and long-term acute care). Multivariable logistic regression models evaluated the association between discharge location, CR attendance, and 1-year mortality. RESULTS: Of the 167,966 patients who met inclusion criteria, 34.1% discharged to an ECF. Overall CR usage rate was 53.9%. Unadjusted and adjusted CR use was lower among patients discharged ECFs versus those discharged home (42.1% vs 60.0%; adjusted odds ratio, 0.66; P < .001). Patients discharged to long-term acute care were less likely to use CR than those discharged to skilled nursing facility or inpatient rehabilitation (reference category: home; adjusted odds ratio for long-term acute care, 0.36, adjusted odds ratio for skilled nursing facility, 0.69, and adjusted odds ratio for inpatient rehabilitation, 0.71; P < .001). CR attendance was associated with a greater reduction in adjusted 1-year mortality in patients discharged to ECFs (9.7% reduction) versus those discharged home (4.3% reduction). CONCLUSIONS: In this national analysis of Medicare beneficiaries, discharge to ECF was associated with lower CR use, despite a greater association with improved 1-year mortality. Interventions aimed at increasing CR enrollment at ECFs may improve CR use and advance surgical quality.

Dietary Counseling Documentation Among Patients Recently Hospitalized for Cardiovascular Disease.

BACKGROUND: Diet intervention forms the cornerstone for cardiovascular disease (CVD) management. OBJECTIVE: The objective was to measure the frequency of dietary counseling documentation for patients recently hospitalized with CVD. DESIGN: This was an observational study. PARTICIPANTS AND SETTING: Patients were included from the Michigan Value Collaborative Multipayer Claims Registry from October 2015 to February 2020. MAIN OUTCOME MEASURE: The study measured the frequency of medical claims that document dietary counseling ≤90 days after hospitalization (ie, an episode of care) for CVD events (coronary artery bypass grafting, acute myocardial infarction, congestive heart failure, and percutaneous coronary intervention). Dietary counseling documentation was defined as having an encounter-level International Classification of Diseases 10th Revision code for dietary counseling or current procedural terminology code for medical nutrition therapy or cardiac rehabilitation. STATISTICAL ANALYSES PERFORMED: Multivariable logistic regression was used to measure variation in documentation across gender, age, comorbidities, hospital geography, CVD event, and insurer. RESULTS: There were 175,631 episodes of care (congesitve heart failure 47.1%, acute myocardial infarction 28.7%, percutaneous coronary intervention 17.0%, and coronary artery bypass grafting 7.3%) among 146,185 individuals. Most episodes occurred among men (55.8%) and those older than age 65 years (71.9%). Dietary counseling was documented for 22.8% of episodes and was more common as cardiac rehabilitation (18.6%) than other encounter types (5.1%). In multivariable analysis, there was lower odds for dietary counseling documentation among those older than age 65 years (odds ratio [OR] 0.77; P < .001), women (OR 0.83; P < .001), with chronic kidney disease (OR 0.74; P < .001), or diabetes (OR 0.95; P < .001), but greater odds for those with obesity (OR 1.28; P < .001) and nonmetropolitan hospitals (OR 1.31; P < .001). Compared with coronary artery bypass grafting, acute myocardial infarction (OR 0.29; P < .001), confestive heart failure (OR 0.12; P < .001), and percutaneous coronary intervention (OR 0.36; P < .001) episodes had lower odds to have dietary counseling coded. Compared with Traditional Medicare, Medicaid and Medicare Advantage health maintenance organization plans had lower odds, whereas Commercial or Medicare Advantage preferred provider organization and Commercial health maintenance organization plans had higher odds to have dietary counseling documented. Results were mostly similar when evaluated by race. CONCLUSIONS: Dietary counseling was infrequently documented after hospitalization for CVD episodes in medical claims in a Michigan-based multipayer claims database with large variation by reason for hospitalization and patient factors.

Cardiac Rehabilitation Use After Heart Failure Hospitalization Associated With Advanced Heart Failure Center Status.

PURPOSE: Cardiac rehabilitation (CR) is an evidence-based, guideline-endorsed therapy for patients with heart failure with reduced ejection fraction (HFrEF) but is broadly underutilized. Identifying structural factors contributing to increased CR use may inform quality improvement efforts. The objective here was to associate hospitalization at a center providing advanced heart failure (HF) therapies and subsequent CR participation among patients with HFrEF. METHODS: A retrospective analysis was performed on a 20% sample of Medicare beneficiaries primarily hospitalized with an HFrEF diagnosis between January 2008 and December 2018. Outpatient claims were used to identify CR use (no/yes), days to first session, number of attended sessions, and completion of 36 sessions. The association between advanced HF status (hospitals performing heart transplantation or ventricular assist device implantations) and CR participation was evaluated with logistic regression, accounting for patient, hospital, and regional factors. RESULTS: Among 143 392 Medicare beneficiaries, 29 487 (20.6%) were admitted to advanced HF centers (HFCs) and 5317 (3.7%) attended a single CR session within 1 yr of discharge. In multivariable analysis, advanced HFC status was associated with significantly greater relative odds of participating in CR (OR = 2.20: 95% CI, 2.08-2.33; P < .001) and earlier initiation of CR participation (-8.5 d; 95% CI, -12.6 to 4.4; P < .001). Advanced HFC status had little to no association with the intensity of CR participation (number of visits or 36 visit completion). CONCLUSIONS: Medicare beneficiaries hospitalized for HF were more likely to attend CR after discharge if admitted to an advanced HFC than a nonadvanced HFC.

Association of a Medicare Mandate for Shared Decision-Making With Cardiac Device Utilization.

This cohort study evaluates the association between a Medicare shared decision-making mandate for use of implantable cardioverter defibrillators with the rate of use for this device.

Hospital variation of outcomes in status epilepticus.

OBJECTIVE: Understanding factors driving variation in status epilepticus outcomes would be critical to improve care. We evaluated the degree to which patient and hospital characteristics explained hospital-to-hospital variability in intubation and postacute outcomes. METHODS: This was a retrospective cohort study of Medicare beneficiaries admitted with status epilepticus between 2009 and 2019. Outcomes included intubation, discharge to a facility, and 30- and 90-day readmissions and mortality. Multilevel models calculated percent variation in each outcome due to hospital-to-hospital differences. RESULTS: We included 29 150 beneficiaries. The median age was 68 years (interquartile range [IQR] = 57-78), and 18 084 (62%) were eligible for Medicare due to disability. The median (IQR) percentages of each outcome across hospitals were: 30-day mortality 25% (0%-38%), any 30-day readmission 14% (0%-25%), 30-day status epilepticus readmission 0% (0%-3%), 30-day facility stay 40% (25%-53%), and intubation 46% (20%-61%). However, after accounting for many hospitals with small sample size, hospital-to-hospital differences accounted for 2%-6% of variation in all unadjusted outcomes, and approximately 1%-5% (maximally 8% for 30-day readmission for status epilepticus) after adjusting for patient, hospitalization, and/or hospital characteristics. Although many characteristics significantly predicted outcomes, the largest effect size was cardiac arrest predicting death (odds ratio = 10.1, 95% confidence interval = 8.8-11.7), whereas hospital characteristics (e.g., staffing, accreditation, volume, setting, services) all had lesser effects. SIGNIFICANCE: Hospital-to-hospital variation explained little variation in studied outcomes. Rather, certain patient characteristics (e.g., cardiac arrest) had greater effects. Interventions to improve outcomes after status epilepticus may be better focused on individual or prehospital factors, rather than at the inpatient systems level.

Geographic variation in aortic stenosis treatment and outcomes among Medicare beneficiaries in the United States.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has changed the landscape of aortic stenosis (AS) management. AIM: To describe and evaluate geographic variation in AS treatment and outcomes among a sample of Medicare beneficiaries. METHODS: A retrospective analysis of administrative claims data was conducted on a 20% sample of Medicare fee-for-service beneficiaries aged 65 and older with a diagnosis of AS (2015-2018). Estimates of demographic, comorbidity, and healthcare resources were obtained from Medicare claims and the Dartmouth Atlas of Health Care at the hospital referral region (HRR), which represents regional tertiary medical care markets. Linear regression was used to explain HRR-level variation in rates of surgical aortic valve replacement (SAVR) and TAVR, and 1-year mortality and readmission rates. RESULTS: A total of 740,899 beneficiaries with AS were identified with a median prevalence of AS of 39.9 per 1000 Medicare beneficiary years. The average HRR-level rate of SAVR was 26.3 procedures per 1000 beneficiary years and the rate of TAVR was 20.3 procedures per 1000 beneficiary years. HRR-level comorbidities and number of TAVR centers were associated with a lower SAVR rate. Demographics and comorbidities explained most of the variation in HRR-level 1-year mortality (15.2% and 18.8%) and hospitalization rates (20.5% and 16.9%), but over half of the variation remained unexplained. CONCLUSION: Wide regional variation in the treatment and outcomes of AS was observed but were largely unexplained by patient factors and healthcare utilization. Understanding the determinants of AS treatment and outcomes can inform population health efforts for these patients.

Hospital Variation in Skilled Nursing Facility Use After Coronary Artery Bypass Graft Surgery.

BACKGROUND: Over 20% of patients are discharged to a skilled nursing facility (SNF) after coronary artery bypass graft surgery, but little is known about specific drivers for postdischarge SNF use. The purpose of this study was to evaluate hospital variation in SNF use and its association with postoperative outcomes after coronary artery bypass graft. METHODS AND RESULTS: A retrospective study design utilizing Medicare Provider Analysis and Review files was used to evaluate SNF use among 70 509 beneficiaries undergoing coronary artery bypass graft, with or without valve procedures, between 2016 and 2018. A total of 17 328 (24.6%) were discharged to a SNF, ranging from 0% to 88% across 871 hospitals. Multilevel logistic regression models identified significant patient-level predictors of discharge to SNF including increasing age, comorbidities, female sex, Black race, dual eligibility, and postoperative complications. After adjusting for patient and hospital factors, 15.6% of the variation in hospital SNF use was attributed to the discharging hospital. Compared with the lower quartile of hospital SNF use, hospitals in the top quartile of SNF use had lower risk-adjusted 1-year mortality (12.5% versus 8.6%, P<0.001) and readmission (59.9% versus 49.8%, P<0.001) rates for patients discharged to a SNF. CONCLUSIONS: There is high variability in SNF use among hospitals that is only partially explained by patient characteristics. Hospitals with higher SNF utilization had lower risk-adjusted 1-year mortality and readmission rates for patients discharged to a SNF. More work is needed to better understand underlying provider and hospital-level factors contributing to SNF use variability.

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization.

BACKGROUND: Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes. METHODS: A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization. RESULTS: A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles. CONCLUSIONS: Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.

BACKGROUND: Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. METHODS: A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes. RESULTS: In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001). CONCLUSIONS: The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.

Hospital performance in a statewide commercial insurer episode-based incentive program.

OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

Cardiac Rehabilitation Reduces 2-Year Mortality After Coronary Artery Bypass Grafting.

BACKGROUND: Cardiac rehabilitation (CR) is a supervised outpatient exercise and risk reduction program offered to patients who have undergone coronary revascularization procedures. Multiple professional societal guidelines support the use of CR after coronary artery bypass grafting (CABG) based on studies in combined percutaneous coronary intervention and CABG populations with surrogate outcomes. This statewide analysis of patients undergoing CABG evaluated the relationship between CR use and long-term mortality. METHODS: Medicare fee-for-service claims were linked to surgical data for patients discharged alive after isolated CABG from January 1, 2015, through September 30, 2019. Outpatient facility claims were used to identify any CR use within 1 year of discharge. Death within 2 years of discharge was the primary outcome. Mixed-effects logistic regression was used to predict CR use, adjusting for a variety of comorbidities. Unadjusted and inverse probability treatment weighting (IPTW) were used to compare 2-year mortality among CR users vs nonusers. RESULTS: A total of 3848 of 6412 patients (60.0%) were enrolled in CR for an average of 23.2 (SD, 12.0) sessions, with 770 of 6412 (12.0%) completing all recommended 36 sessions. Logistic regression identified increasing age, discharge to home (vs extended care facility), and shorter length of stay as predictors of postdischarge CR use (P < .05). Unadjusted and IPTW analyses showed significant reduction in 2-year mortality in CR users compared with CR nonusers (unadjusted: 9.4% reduction; 95% CI, 10.8%-7.9%; P < .001; IPTW: -4.8% reduction; 95% CI, 6.0%-3.5%; P < .001). CONCLUSIONS: These data suggest that CR use is associated with lower 2-year mortality. Future quality initiatives should consider identifying and addressing root causes of poor CR enrollment and completion.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis.

BACKGROUND: There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. OBJECTIVE: This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. STUDY DESIGN: We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. RESULTS: There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). CONCLUSION: This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Racial and ethnic disparities in diagnosis, management and outcomes of aortic stenosis in the Medicare population.

IMPORTANCE: Aortic stenosis (AS) is one of the most common heart valve conditions and its incidence and prevalence increases with age. With the introduction of transcatheter aortic valve replacement (TAVR), racial and ethnic disparities in AS diagnosis, treatment and outcomes is poorly understood. OBJECTIVE: In this study we assessed racial and ethnic disparities in AS diagnosis, treatment, and outcomes among Medicare beneficiaries. DESIGN: We conducted a population-based cohort study of inpatient, outpatient, and professional claims from a 20% sample of Medicare beneficiaries. MAIN OUTCOMES AND MEASURES: Incidence and Prevalence was determined among Medicare Beneficiaries. Outcomes in this study included management; the number of (non)-interventional cardiology and cardiothoracic surgery evaluation and management (E&M) visits, and number of transthoracic echocardiograms (TTE) performed. Treatment, which was defined as Surgical Aortic Valve Replacement and Transthoracic Aortic Valve Replacement. And outcomes described as All-cause Hospitalizations, Heart Failure Hospitalization and 1-year mortality. RESULTS: A total of 1,513,455 Medicare beneficiaries were diagnosed with AS (91.3% White, 4.5% Black, 1.1% Hispanic, 3.1% Asian and North American Native) between 2010 and 2018. Annual prevalence of AS diagnosis was lower for racial and ethnic minorities compared with White patients, with adjusted rate ratios of 0.66 (95% CI 0.65 to 0.68) for Black patients, 0.67 (95% CI 0.64 to 0.70) for Hispanic patients and 0.75 (95% CI 0.73 to 0.77) for Asian and North American Native patients as recent as 2018. After adjusting for age, sex and comorbidities, cardiothoracic surgery E&M visits and treatment rates were significantly lower for Black, Hispanic and Asian and North American Native patients compared with White patients. All-cause hospitalization rate was higher for Black and Hispanic patients compared with White patient. 1-year mortality was higher for Black patients, while Hispanic and Asian and North American Native patients had lower 1-year mortality compared with White patients. CONCLUSIONS AND RELEVANCE: We demonstrated significant racial and ethnic disparities in the diagnosis, management and outcomes of AS. The factors driving the persistence of these disparities in AS care need to be elucidated to develop an equitable health care system.

Improving the Quality of Upper Urinary Tract Stone Surgery: External Validation of a Statewide Collaborative's Efforts to Reduce Emergency Department Visits After Ureteroscopy.

PURPOSE: The ROCKS (Reducing Operative Complications from Kidney Stones) program in MUSIC (Michigan Urological Surgery Improvement Collaborative) was created to optimize ureteroscopy outcomes. Through data collection, distribution of reports, patient education, and standardization of medication, post-ureteroscopy emergency department visits in Michigan have declined. It is unclear whether this is because of statewide quality efforts or due to national trends. We therefore sought to understand emergency department visit rates in Michigan compared to a national data set. MATERIALS AND METHODS: We compared the MUSIC ROCKS clinical registry in Michigan against a national cohort, Optum's de-identified Clinformatics Data Mart, from 2016-2021 (excluding Michigan). We identified patients who underwent ureteroscopy and the proportion who had a postoperative emergency department visit within 30 days. Emergency department rates were modeled over time, adjusting for age, gender, comorbidity, and ureteral stenting. RESULTS: We identified 24,688 patients in MUSIC ROCKS and 99,340 in the Clinformatics Data Mart database who underwent ureteroscopy. The risk-adjusted emergency department visit rate in MUSIC ROCKS significantly declined over the study period (10.5% in 2016 to 6.9% in 2021, P < 0.001) while the mean emergency department visit rate in the Clinformatics Data Mart cohort was 9.9% and did not change over time (9.6% in 2016 to 10% in 2021). Comparing emergency department visits between the cohorts, the MUSIC ROCKS rate significantly declined relative to the Clinformatics Data Mart (P < 0.001) over the study period. CONCLUSIONS: Postoperative emergency department visit rates in Michigan have declined significantly after ureteroscopy since the establishment of MUSIC ROCKS. This decline outpaced national rates, providing evidence that systematic quality initiatives can improve urological care.

Failure to rescue: A candidate quality metric for durable left ventricular assist device implantation.

OBJECTIVE: Failure to rescue (FTR), defined as death after a complication, is recognized as a principal driver of variation in mortality among hospitals. We evaluated FTR as a quality metric in patients who received durable left ventricular assist devices (LVADs) using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. METHODS: Data on 13,617 patients who received primary durable LVADs from April 2012 to October 2017 at 131 hospitals that performed at least 20 implants were analyzed from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. Rates of major complications and FTR were compared across risk-adjusted in-hospital mortality terciles (low, medium, high) and hospital volume. Logistic regression was used to estimate expected FTR rates on the basis of patient factors for each major complication. RESULTS: The overall unadjusted in-hospital mortality rate was 6.96%. Risk-adjusted in-hospital mortality rates varied 3.1-fold across terciles (low, 3.3%; high, 10.3%; P trend <.001). Rates of major complications varied 1.1-fold (low, 34.0%; high, 38.8%; P < .0001). Among patients with a major complication, 854 died in-hospital for an FTR rate of 17.7%, with 2.8-fold variation across mortality terciles (low, 8.5%; high, 23.9%; P < .0001). FTR rates were highest for renal dysfunction requiring dialysis (45.3%) and stroke (36.5%). Higher average annual LVAD volume was associated with higher rates of major complications (<10 per year, 26.7%; 10-20 per year, 34.0%; 20-30 per year, 34.0%; >30 per year, 40.1%; P trend <.0001) whereas hospitals implanting <10 per year had the highest FTR rate (<10 per year, 23.5%; 10-20 per year, 16.5%; 20-30 per year, 17.0%; >30 per year, 17.9%; P = .03). CONCLUSIONS: FTR might serve as an important quality metric for durable LVAD implant procedures, and identifying strategies for successful rescue after complications might reduce hospital variations in mortality.

Association of Elective Surgical Volume With State Executive Order Curtailing Elective Surgery in Michigan During the COVID-19 Pandemic.

OBJECTIVE: Our objective was to evaluate changes in elective surgical volume in Michigan while an executive order (EO) was in place curtailing elective surgery during the COVID-19 pandemic. SUMMARY BACKGROUND DATA: Many state governors enacted EOs curtailing elective surgery to protect scare resources and generate hospital capacity for patients with COVID-19. Little is known of the effectiveness of an EO on achieving a sustained reduction in elective surgery. METHODS: This retrospective cohort study of data from a statewide claims-based registry in Michigan includes claims from the largest private payer in the state for a representative set of elective operations on adult patients from February 2 through August 1, 2020. We reported trends in surgical volume over the period the EO was in place. Estimated backlogs in elective surgery were calculated using case counts from the same period in 2019. RESULTS: Hospitals achieved a 91.7% reduction in case volume before the EO was introduced. By the time the order was rescinded, hospitals were already performing elective surgery at 60.1% of pre-pandemic case rates. We estimate that a backlog of 6419 operations was created while the EO was in effect. Had hospitals ceased elective surgery during this period, an additional 18% of patients would have experienced a delay in surgical care. CONCLUSIONS: Both the introduction and removal of Michigan's EO lagged behind the observed ramp-down and ramp-up in elective surgical volume. These data suggest that EOs may not effectively modulate surgical care and could also contribute to unnecessary delays in surgical care.