Inpatient and Postdischarge Outcomes Following Elective Craniotomy for Mass Lesions.

BACKGROUND: Interpretation of hospital quality requires objective evaluation of both inpatient and postdischarge adverse outcomes (AOs). OBJECTIVE: To develop risk-adjusted predictive models for inpatient and 90-d postdischarge AOs in elective craniotomy and apply those models to individual hospital performance to provide benchmarks to improve care. METHODS: The Medicare Limited Dataset (2012-2014) was used to define all elective craniotomy procedures for mass lesions in patients ≥65 yr. Predictive logistic models were designed for inpatient mortality, inpatient prolonged length of stay, 90-d postdischarge deaths without readmission, and 90-d readmissions after exclusions. The total observed patients with one or more AOs were then compared to predicted AO values, and z-scores were computed for each hospital that met minimum volume requirements. Risk-adjusted AO rates allowed stratification of eligible hospitals into deciles of performance. RESULTS: The hospital evaluation was performed for 223 facilities with 7624 patients that met criteria. A total of 849 patients (11.1%) died inclusive of 90 d postdischarge; 635 (8.3%) were 3σ length-of-stay outliers; and 1928 patients (25.3%) with one or more 90-d readmissions; 2716 patients experienced one or more AOs (35.6%). Six hospitals were 2 z-scores better than average, and 8 were 2 z-scores poorer. The median risk-adjusted AO rate was 18% for the first decile and 53.4% for the 10th decile. CONCLUSION: There was a 35% difference between best and suboptimal performing hospitals for this operation. Hospitals must know their risk-adjusted AO rates and benchmark their results to inform processes of care redesign.

The impact of clinical vs administrative claims coding on hospital risk-adjusted outcomes.

BACKGROUND: Comorbid condition and hospital risk-adjusted outcomes prevalence were compared based on clinical registry vs administrative claims data. HYPOTHESIS: Risk-adjusted outcomes will vary depending on the source of comorbidity data used. METHODS: Clinical data from hospitalized Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) non-ST-segment elevation myocardial infarction (NSTEMI) patients ≥65 years was linked to Medicare claims. Eight common comorbid conditions were coded and compared between registry data (derived from medical record review) and claims data; hospital-level observed vs expected ratios and outlier status for 30-day readmission and mortality were calculated using logistic generalized estimating equations for clinical vs claims data. RESULTS: Of 68 199 NSTEMI patients, 48.1% were female, 86.9% were white, and median age was 78. Degree of agreement between data sources for comorbid condition prevalence was 67.8% for myocardial infarction and 89.3% for diabetes. Overall, multivariable model performance was similar: Medicare mortality c-statistics is 0.69 vs CRUSADE is 0.71; readmission c-statistics is 0.59 for both. Hospital ratings were similar regardless of data source (mortality, R2 = 0.97863; readmission, R2 = 0.97858). Eighty-two hospitals were mortality outliers in claims-based models; of these, 70 were outliers in registry-based models. Forty-five hospitals were readmission outliers in claims-based models; of these, 39 were outliers in registry-based models. CONCLUSIONS: There were significant differences in individual comorbid condition prevalence when derived from registries vs claims, but hospital-level outcomes were comparable.

Risk-adjusted regional outcomes in elective medicare colorectal surgery.

BACKGROUND: Regional differences in utilization of services in healthcare are commonly understood, but risk-adjusted evaluation of outcomes has not been done. METHODS: Risk-adjusted adverse outcomes (AOs) for elective Medicare colorectal resections were studied for 2012-2014. Risk-adjusted metrics were inpatient deaths, prolonged postoperative length-of-stay, 90-day post-discharge deaths, and 90-day relevant post-discharge readmissions. The nine Census Bureau regions of the U.S. were evaluated by using standard deviations of predicted adverse outcomes to evaluate observed versus expected events. RESULTS: Overall AO rate was 24.3% from 86,624 patients in 1497 hospitals. Region 9 (Pacific) had the best outcomes (z-score = -3.06; risk-adjusted AO rate = 22.9%) and Region 1 (New England) the poorest (z-score = +1.86; risk-adjusted AO rate = 25.4%). CONCLUSIONS: A 4.9 SD difference exists among the best and poorest performing regions in risk-adjusted colorectal surgery outcomes. Alternative Payment Models should consider regional benchmarks as a variable for the evaluation of quality and pricing of episodes of care.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery.

BACKGROUND CONTEXT: Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs. PURPOSE: To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery. STUDY DESIGN/SETTING: To identify the significant risk factors associated with AOs and to develop risk models that measure performance. PATIENT SAMPLE: Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset. OUTCOME MEASURES: The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models. METHODS: Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals. RESULTS: There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%. CONCLUSIONS: Differences among hospitals defines opportunities for care improvement.

Surgeon-level reporting presented by funnel plot is understood by doctors but inaccurately interpreted by members of the public.

INTRODUCTION: Risk-adjusted outcome data for general surgeons practicing in the United Kingdom were published for the first time in 2013 with the aim of increasing transparency, improving standards, and providing the public with information to aid decision making. Most specialties used funnel plots to present their data. We assess the ability of members of the public (MoP), medical students, nonsurgical doctors (NSD), and surgeons to understand risk-adjusted surgical outcome data. MATERIAL AND METHODS: A fictitious outcome dataset was created and presented in the form of a funnel plot to 10 participants from each of the aforementioned group. Standard explanatory text was provided. Each participant was given 5 minutes to review the funnel plot and complete a questionnaire. For each question, there was only 1 correct answer. RESULTS: Completion rate was 100% (n = 40). No difference existed between NSD and surgeons. A significant difference for identification of the "worst performing surgeon" was noted between surgeons and MoP (p < 0.01) and between NSD and MoP (p < 0.01). Half of medical students and MoP claimed they would use this information to aid decision making compared with 80% of doctors. MoP reported the funnel plot significantly "more difficult" to interpret than surgeons did (p < 0.01) and NSD (p < 0.01). CONCLUSIONS: MoP found these data significantly more "difficult to understand" and were less likely to both spot "outliers" and use this data to inform decisions than doctors. Surgeons should be aware that outcome data may require an alternative method of presentation to be understood by MoP.

Prediction models of Medicare 90-day postdischarge deaths, readmissions, and costs in bowel operations.

BACKGROUND: The 90-day postdischarge morbidity and mortality rates following elective and emergent bowel surgery remain poorly defined. METHODS: The 2009 to 2011 Medicare inpatient files for patients undergoing elective and emergent small and large bowel operations in 1,024 hospitals that passed present-on-admission coding accuracy standards had prediction models designed for inpatient mortality, prolonged postoperative length of hospital stay (prLOS), 90-day postdischarge mortality and readmissions, and total hospital costs. RESULTS: Of 118,758 patients studied, there was a 4.7% inpatient mortality rate and 7.3% prLOS among live discharges. An additional 7,586 deaths and 26,969 readmissions occurred within 90 days of discharge. Prolonged preoperative and prolonged postoperative hospitalizations were significant (P < .0001) variables in predicting postdischarge deaths and readmissions. Total hospital costs were increased by over $18,000 per adverse outcome. CONCLUSION: Postdischarge deaths and readmissions are more common than inpatient adverse events of death and prLOS in elective and emergent Medicare large and small bowel operations.

ACS national surgical quality improvement program: targeting quality improvement in Canadian pediatric surgery.

PURPOSE: The pediatric NSQIP program is in the early stages of facilitated surgical quality improvement for children. The objective of this study is to describe the initial experience of the first Canadian Children's Hospital participant in this program. METHOD: Randomly sampled surgical cases from the "included" case list were abstracted into the ACS-NSQIP database. These surgical procedure-specific data incorporate patient risk factors, intraoperative details, and 30 day outcomes to generate annual reports which provide hierarchical ranking of participant hospitals according to their risk-adjusted outcomes. RESULTS: Our first risk-adjusted report identified local improvement opportunities based on our rates of surgical site infection (SSI) and urinary tract infection (UTI). We developed and implemented an engagement strategy for our stakeholders, performed literature reviews to identify practice variation, and conducted case control studies to understand local risk factors for our SSI/UTI occurrences. We have begun quality improvement activities targeting reduction in rates of SSI and UTI with our general surgery division and ward nurses, respectively. CONCLUSIONS: The NSQIP pediatric program provides high quality outcome data that can be used in support of quality improvement. This process requires multidisciplinary teamwork, systematic stakeholder engagement, clinical research methods and process improvement through engagement and culture change.

Medicare post-discharge deaths and readmissions following elective surgery.

BACKGROUND: The frequency of 90-day, postdischarge deaths and readmissions in Medicare patients undergoing elective surgical procedures has not been well studied. METHODS: The Medicare MedPar database for 2009 to 2010 was used to develop inpatient risk-adjusted, postoperative length-of-stay (RApoLOS) prediction models for live discharges in 21 categories of elective operations. Moving average control charts were used in each category to define RApoLOS outliers (>3σ). The relationships between RApoLOS outliers and all postdischarge deaths and readmissions within 90 days of discharge were assessed. RESULTS: The inpatient mortality rate was .5%. Of 2,054,189 live discharges, 147,292 (7%) were RApoLOS outliers. There were 14,657 postdischarge deaths (.7%) and 187,566 readmissions (9%). RApoLOS outliers had a 3.5% death rate and a 17% rate of readmission, while those found not to be RApoLOS outliers had a .5% death rate and a 9% readmission rate (P < .0001). CONCLUSIONS: RApoLOS outliers have increased rates of postdischarge deaths and readmissions.