Hospital experience predicts outcomes after high-risk geriatric surgery.
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ABSTRACT: Background
Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery.Methods
Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility.Results
There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003).Conclusion
Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.
SUBMITTER: Dworsky JQ
PROVIDER: S-EPMC8019519 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportancePalliative care has the potential to improve care for patients and families undergoing high-risk surgery.ObjectiveTo characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.Design, setting, and participantsThis secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.ExposuresPalliative-care consultation within 30 days before or 90 days after surgery.Main outcomes and measuresThe outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.ResultsA total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.Conclusions and relevanceReceipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
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Project description:Study objectivePrevious studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation.MethodsWe analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates.ResultsDuring 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92 (95% CI 0.67 to 1.26).ConclusionRescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.
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