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Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

ABSTRACT: OBJECTIVE:To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals BACKGROUND:High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes. METHODS:Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals. RESULTS:Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042). CONCLUSIONS:Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

SUBMITTER: Funk LM

PROVIDER: S-EPMC7065506 | biostudies-literature | 2011 May

REPOSITORIES: biostudies-literature

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Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

Funk Luke M LM Gawande Atul A AA Semel Marcus E ME Lipsitz Stuart R SR Berry William R WR Zinner Michael J MJ Jha Ashish K AK

Annals of surgery 20110501 5

<h4>Objective</h4>To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals<h4>Background</h4>High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes.<h4>Methods</h4>Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who u ...[more]

PMID: 21422913

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Project description:Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals.To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions.Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older.Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals).Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions.The sample consisted of 21?451?824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P?<?.001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P?<?.001). After stratifying by hospital size, 187 large (?400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P?<?.001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P?=?.003). Among small (?99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P?=?.01).Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.

Project description:BackgroundPhysician medical specialties place specific demands on medical staff. Often patients have multiple co-morbidities, frailty is common, and mortality rates are higher than other specialties such as surgery. The key intervention for patients admitted under physician subspecialties is the care provided on the ward. The current evidence base to inform staffing in physician medical specialty wards is limited. The aim of this analysis is to investigate the association between medical staffing levels within physician medical specialties and mortality.MethodsThis study is a cross-sectional analysis of national data, which is aggregated at provider level. Medical beds per senior, middle grade and junior physicians employed in physician medical specialties were calculated from national employment records for acute hospitals in England, in 2017. Outcome measures included unadjusted mortality rate and Summary Hospital-level Mortality Indicator (SHMI) in physician medical specialties. Both Raw mortality and SHMI include deaths during admission or within 30 days following discharge. Linear regression models were constructed for each medical staffing grade for unadjusted mortality, SHMI and SHMI adjusted for local provider factors.FindingsThe mean number of medical beds per senior, middle grade and junior physicians were 7.3(SD 2.5), 19.7(11.5), 10.1(3.1) respectively. Lower bed numbers per medical staff grade were associated with lower than expected mortality by SHMI; senior(Coefficient 0.012(95%CI:0.005-0.018),p = 0.001), middle grade(0.002(0.0002-0.005),p = 0.032) and junior(0.008(0.002-0.015),p = 0.014). Hospital providers were more likely to achieve a better than expected mortality (SHMI<1) if beds per physician were lower than; 5.3, 14.6 and 9.0 for senior, middle grade and junior doctors respectively.InterpretationAcute hospital providers with fewer beds per medical staff of all grades are associated with lower than expected mortality.FundingNo external funding is associated with this analysis.

Project description:ObjectivesTo determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations.DesignObservational study.Setting4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017.Participants4?242?684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).Main outcome measuresRisk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission.ResultsPatients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06).ConclusionsUS hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.

Project description:ImportanceLittle research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures.ObjectiveTo investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York.Design, settings, and participantsThis cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals.ExposuresSurgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons.Main outcomes and measuresTemporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics.ResultsThere were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA.Conclusions and relevanceThe OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.

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Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

Publications

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

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