1,720,962 research outputs found
Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database
No full textBackground: Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. Methods: We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. Results: The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6–1.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by 6.98 million/year. Conclusion: HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care
Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma
No full textBackground: A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS). Methods: Using the National Cancer Database (NCDB) 2004–2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS. Results: Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%–44%, p < 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%–15%, p < 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88–0.97, p < 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83–0.91, p < 0.001) were independently associated with improved OS. Conclusions: Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival
Variation in Medicare Payments and Reimbursement Rates for Hepatopancreatic Surgery Based on Quality: Is There a Financial Incentive for High-Quality Hospitals?
No full textBackground: To better define the financial impact of high-quality care for payers and hospitals, we compared outcomes and Medicare payments between high-quality (HQ) and low-quality (LQ) hospitals after hepatopancreatic surgery. Study Design: Between 2013 through 2015, a total of 15,874 Medicare beneficiaries underwent hepatopancreatic surgery. Using the entire cohort, multivariable logistic regression was performed to categorize hospitals into quintiles based on the probability of experiencing a major complication; HQ (bottom 20%) and LQ (top 20%) hospitals were identified. Only HQ and LQ hospitals were included in the final propensity matching to compare payments. Major complication was defined as a complication associated with a length of stay of >75th percentile. Incremental payment and cost of complication were estimated using multivariable linear regression. Results: Major complications occurred in 9.7% (n = 309 of 3,182) at HQ hospitals compared with 20% (n = 625 of 3,130) at LQ hospitals (p < 0.001). The incremental increased payment associated with major complication was 42,935. The Medicare reimbursement rate was also 6% lower at both HQ and LQ hospitals when a major complication occurred vs not; however, HQ hospitals had a 3% higher reimbursement rate compared with LQ hospitals when a major complication did not occur (p = 0.002). Mean unadjusted Medicare payment was lower at HQ hospitals by 5,165 per patient vs LQ hospitals (p < 0.001), largely because HQ hospitals had a lower overall incidence of major complications (n = 315 vs n = 625). By having 310 fewer patients with a major complication, HQ hospitals collectively achieved 3.1 million/year in Medicare savings. Conclusions: High-quality hospitals are able to achieve substantial Medicare savings by avoiding major complications. Occurrence of major complications was associated with lower Medicare reimbursement rates at both HQ and LQ hospitals vs when no complications occurred
Synergistic Effects of Perioperative Complications on 30-Day Mortality Following Hepatopancreatic Surgery
No full textBackground: Data on the interaction effect of multiple concurrent postoperative complications relative to the risk of short-term mortality following hepatopancreatic surgery have not been reported. The objective of the current study was to define the interaction effect of postoperative complications among patients undergoing HP surgery on 30-day mortality. Methods: Using the ACS-NSQIP Procedure Targeted Participant Use Data File, patients who underwent HP surgery between 2014 and 2016 were identified. Hazard ratios (HRs) for 30-day mortality were estimated using Cox proportional hazard models. Two-way interaction effects assessing combinations of complications relative to 30-day mortality were calculated using the relative excess risk due to interaction (RERI) in separate adjusted Cox models. Results: Among 26,824 patients, 10,886 (40.5%) experienced at least one complication. Mortality was higher among patients who experienced at least one complication versus patients who did not experience a complication (3.0 vs 0.1%, p < 0.001). The most common complications were blood transfusion (16.9%, n = 4519), organ space infection (12.2%, n = 3273), and sepsis/septic shock (8.2%, n = 2205). Combinations associated with additive effect on mortality included transfusion + renal dysfunction (RERI 12.3, 95% CI 5.2–19.4), pulmonary dysfunction + renal dysfunction (RERI 60.9, 95% CI 38.6–83.3), pulmonary dysfunction + cardiovascular complication (RERI 144.1, 95% CI 89.3–199.0), and sepsis/septic shock + renal dysfunction (RERI 11.5, 95% CI 4.4–18.7). Conclusion: Both the number and specific type of complication impacted the incidence of postoperative mortality among patients undergoing HP surgery. Certain complications interacted in a synergistic manner, leading to a greater than expected increase in the risk of short-term mortality
Procedure-Specific Volume and Nurse-to-Patient Ratio: Implications for Failure to Rescue Patients Following Liver Surgery
No full textBackground: The effect of various hospital characteristics on failure to rescue (FTR) after liver surgery has not been well examined. We sought to examine the relationship between hospital characteristics and FTR after liver surgery. Methods: The 2013–2015 Medicare-Provider Analysis and Review (MEDPAR) database was used to identify Medicare beneficiaries who underwent liver surgery. The effect of various hospital characteristics on FTR was compared among the highest mortality hospitals (HMH) and the lowest mortality hospitals (LMH). Results: Among 4902 patients undergoing hepatectomy, patients treated at HMH had a higher risk of FTR (OR 3.08, 95% CI 2.03–4.66). Hospital factors such as total number of beds (OR 0.80, 95% 0.56–1.15), operating rooms (OR 0.81, 95% 0.57–1.14), and overall hospital surgical volume (OR 0.88, 95% 0.61–1.25) were not associated with FTR (all p > 0.05). In contrast, hospitals with a greater nurse-to-patient ratio had a markedly lower risk of FTR following a complication (OR 0.70, 95% CI 0.54–0.91; p = 0.007) (Table 3). As volume of liver operations and nurse-to-patient ratio decreased the risk of FTR increased (p > 0.001). After risk-adjusting for patient characteristics, both the effect of surgical volume (adjusted OR 0.66, 95% CI 0.46–0.94; p = 0.022) and nurse-to-patient ratio (adjusted OR 0.68, 95% CI 0.51–0.90; p = 0.008) remained strongly associated with FTR. Conclusion: FTR rates varied considerably among hospital performing hepatectomy. Higher procedure-specific hepatectomy volume, as well as a higher nurse-to-patient ratio, accounted for a reduction in the FTR rates. These data highlight the importance of not only procedure volume, but also adequate nurse staffing in reducing FTR and improving mortality following complex procedures such as hepatectomy
Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery
No full textBackground: The relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality. Methods: A retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue). Results: A total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16–1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51–2.09), 30-day readmission (RR 1.21 95% CI 1.06–1.39), 90-day mortality (RR, 1.29, 95% CI 1.01–1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14–1.97). Conclusion: Highest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality
Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery
No full textBackgroundThe impact of time to readmission (TTR) on post-discharge mortality has not been well examined. We sought to define the impact of TTR on postoperative mortality after liver or pancreas surgery.MethodsA retrospective cohort analysis of liver and pancreas surgical patients was conducted using 2013-2015 Medicare Provider Analysis and Review database. Patients were subdivided into TTR groups: 1-5days, 6-15, 15-30, 31-60, 61-90, and no readmission. The association of index complication, readmission causes, TTR, and mortality was assessed.ResultsAmong 18,177 patients, a total of 4485 (24.7%) patients were readmitted within 90days of discharge. Major causes for readmission differed across TTR groups. Patients readmitted within 1-15days were more likely to be readmitted for postoperative infection compared with patients who had a late readmission (1-5days: 63.1% vs. 6-15days: 65.0% vs. 61-90days: 39.3%; P<0.001). In contrast, causes of late readmissions were more likely related to gastrointestinal complications (1-5days: 28.9% vs. 61-90days: 39.7%; P<0.001). Compared with no readmission, 180-day mortality was highest among patients readmitted within 16-30days (aOR 3.60; 95% CI 2.94-4.41). Among patients with index complications, patients who were readmitted within 1-5days had a higher risk-adjusted 180-day mortality than late readmission (1-5days: 37.3% vs. 61-90days: 27.1%) (P<0.001).ConclusionsAmong patients who were readmitted, the incidence of mortality increased with TTR up to 60days after discharge yet decreased thereafter. The relation of TTR and mortality was particularly pronounced among those patients who had an index complication. Future efforts should consider TTR when identifying specific approaches to decrease readmission
Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer
No full textBackground: The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR. Methods: Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR. Results: Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (Δ = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7–12] vs. 14 days [IQR: 10–21]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were 36,775 [IQR: 26,416–54,245] vs. $23,682 [IQR: 16,299–32,996]). Conclusion: CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
- …
