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Objective: To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making. Background: PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making. Methods: We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool. Results: Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42–2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04–2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (−63.3), outpatient management (−54.9), and patient preference (−39.6). PRS was predicted to have high utility (+71). Conclusions: A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making. [ABSTRACT FROM AUTHOR]

Limited data exist evaluating lumen-apposing metal stents (LAMSs) with endoscopic balloon dilation (EBD) for the treatment of benign colorectal anastomotic strictures (BCASs). This study compares outcomes of both interventions. Patients with left-sided BCAS treated with LAMSs versus EBD were identified retrospectively. The primary outcome was a composite of crossover to another intervention to achieve clinical success or recurrence requiring reintervention. Twenty-nine patients (11 LAMS and 18 EBD) were identified with longer follow-up in the EBD group (734 vs 142 days; P =.003). No significant differences were found in the composite outcome, technical success, clinical success, or components of composite outcome. With LAMS, there was a nonsignificant trend toward fewer procedures (2.4 vs 3.3; P =.06) and adverse events (0% vs 16.7%; P =.26). LAMS appears to be as effective as EBD for the treatment of BCAS but may require fewer procedures and may be safer than EBD. [ABSTRACT FROM AUTHOR]

National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis. This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality. A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively. This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems. Summary of Background Data: Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost. Methods: Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level. Results: Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272–$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545–$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals. Conclusions: Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy. Summary background data: Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences. Methods: Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP. Results: In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending. Conclusions: ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers. [ABSTRACT FROM AUTHOR]

Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012–2013) and after (2016–2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P <.0001) without increased readmission rates (8.0% vs 7.6%, P =.10) or payments ($1,087 vs $1,026, P =.14). Emergency department use increased (7.8% vs 8.9%, P <.0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to –16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement. [ABSTRACT FROM AUTHOR]

Objective: To quantify the extent to which payments for laparoscopic and open colectomy are influenced by a surgeon's experience with laparoscopy. Background: Numerous studies suggest that healthcare costs for laparoscopic colectomy are lower than open surgery. None have assessed the importance of surgeon experience on the relative financial benefits of laparoscopy. Methods: We conducted a study of 182,852 national Medicare beneficiaries undergoing laparoscopic or open colectomy between 2010 and 2012. Using instrumental variable methods to account for selection bias, we compared Medicare payments for laparoscopic and open colectomy. We stratified our analysis by surgeons' annual experience with laparoscopic colectomy to determine the influence of provider experience on payments. Results: In the fully adjusted analysis, average episode payments per patient were $2640 [95% confidence interval (CI) −$4091 to −$1189] lower with the laparoscopic approach versus open. Surgeons in the highest quartile of laparoscopic experience demonstrated an average payment savings of $5456 per patient (CI −$7918 to −$2994) in their laparoscopic versus open cases. Among surgeons in the lowest quartile of laparoscopic experience, there was, however, no difference between laparoscopic and open cases (difference: $954, 95% CI −$731 to $2639). Differences in payments were explained by differences in complications rates. Both groups had similar rates of complications for open procedures (least experience, 21%, most experience, 21%; P = 0.45), but differed significantly on rates of complications for laparoscopic cases (least experience, 28%, most experience, 15%; P < 0.01). Conclusions: This population-based study demonstrates that differences in payments between laparoscopic and open colectomy are influenced by surgeon experience. The laparoscopic approach does not reduce payments for patients whose surgeons have limited experience with the procedure. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, although largely ignored thus far, will be key to the value proposition for payers. Methods We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n = 1,655) or SAVR (33 hospitals, n = 4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. Results Payments (± SD) were higher for TAVR than SAVR ($69,388 ± $22,259 versus $66,683 ± $27,377, p < 0.001), while mean hospital length of stay was shorter for TAVR (6.2 ± 5.6 versus 10.2 + 7.5 days, p < 0.001). Index hospitalization payments were $4,374 higher for TAVR (p < 0.001), whereas readmission and post-acute care payments were $1,150 (p = 0.001) and $739 (p = 0.004) lower, respectively, and professional payments were similar. For SAVR, high-volume centers had lower episode payments (difference: 5.0%, $3,255; p = 0.01) and shorter length of stay (10.0 ± 7.5 versus 11.1 ± 7.9 days, p = 0.002) than low volume centers. In contrast, we found no volume–payment relationship among TAVR centers. Conclusions Episode payments were higher for TAVR, despite shorter length of stay. Although not a driver for TAVR, center SAVR volume was inversely associated with payments. These data will be increasingly important to address value-based reimbursement in valve replacement surgery. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the surgical outcomes of emergency operations performed at critical access and non-critical access hospitals. Background: Critical access hospitals are often the only source of surgical care for rural populations. Previous studies have demonstrated that patients undergoing common, elective operations at these rural hospitals have similar outcomes to their urban counterparts. Little is known, however, about the quality of care these hospitals provide for emergency operations for which they are most essential. Methods: We performed a cross-sectional retrospective review of 219,170 urgent or emergency colon resections among Medicare beneficiaries between 2009 and 2012.We comparedmortality, serious complications, reoperation, and readmission rates at critical access and non-critical access hospitals using a multivariable logistic regression to adjust for patient factors (age, sex, race, Elixhauser comorbidities,) indication (cancer, diverticulitis, obstruction, inflammatory bowel disease, bleeding), year of operation, and type of operation. Results: Operative indications were similar at both critical access and noncritical access hospitals with the most common being cancer (38.5% vs 31.1%) followed by diverticulitis (26.9% vs 28.0%). Compared with patients treated at non-critical access hospitals, patients undergoing surgery at critical access hospitals were less likely to have multiple comorbid diseases (% of patients with 2 or more comorbid conditions, 67.5% vs 75.9%; P < 0.01). After accounting for these differences, patients in critical access hospitals had lower risk-adjusted 30-day mortality rates (14.3% vs 16.2%; P = 0.012) and lower rates of serious complications (11.1% vs 27.2%; P < 0.001). However, critical access hospitals had higher rates of reoperation (2.1% vs 1.4%; P = 0.009) and readmissions (22.3% vs 19.4%; P < 0.001). Conclusions: For emergency colectomy procedures,Medicare beneficiaries in critical access hospitals experienced lower mortality rates but more frequent reoperation and readmission. These findings suggest that critical access hospitals provide safe, essential emergency surgical care, but may need more resources for postoperative care coordination in these high-risk operations. [ABSTRACT FROM AUTHOR]

Background Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors. Methods We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak. Results Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m 2 , tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 10 9 /L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak. Conclusion This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement. [ABSTRACT FROM AUTHOR]

Objective: To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery. Background: Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. Methods: Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). Results: There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. Conclusions: Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative. Background: Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals. Methods: We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics. Results: Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01). Conclusions: Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective. [ABSTRACT FROM AUTHOR]

Background Patients who undergo a colorectal operation that includes a new ileostomy incur high rates of readmission. Ostomates face a steep learning curve to master the skills and knowledge needed for success at home. We designed and implemented a patient-centered checklist promoting independence and validating self-care knowledge and care skills and evaluated its effect on readmissions after ileostomy creation. Methods On a single inpatient unit, new ileostomy patients were taught and evaluated using a novel postoperative self-care checklist, while perioperative care for ostomates remained unchanged elsewhere in the institution. In a retrospective cohort including all consecutive ileostomy patients from 2 years before (period 1) and 1 year after (period 2) the checklist implementation, we identified univariable predictors of readmission within 30 days of discharge and used a multivariable, difference-in-differences approach to compare trends in readmission between the intervention and control units. Results Of the 430 patients in the study period, there were 116 with readmissions (26%). Readmitted patients had significantly greater all patient refined diagnosis related group weights (3.6 vs 3.3, P = .006) and longer initial duration of stay (13.3 vs 11.3 days, P = .006), and they were more likely to be emergency admissions (49% vs 38%, P = .04). The readmission rate on the intervention unit decreased from 28% in period 1 to 20% in period 2. The logistic regression-based difference-in-differences approach revealed that implementation of the checklist was an independent negative predictor of readmission ( P = .04). Conclusion Implementation of a patient-centered, self-care–oriented postoperative education checklist was associated with significantly reduced odds of readmission after ileostomy creation. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to identify hospital characteristics associated with variation in patient disposition after emergent surgery. Summary background data: Colon resections in elderly patients are often done in emergent settings. Although these operations are known to be riskier, there are limited data regarding postoperative discharge destination. Methods: We evaluated Medicare beneficiaries who underwent emergent colectomy between 2008 and 2010. Using hierarchical logistic regression, we estimated patient and hospital-level risk-adjusted rates of nonhome discharges. Hospitals were stratified into quintiles based on their nonhome discharge rates. Generalized linear models were used to identify hospital structural characteristics associated with nonhome discharges (comparing discharge to skilled nursing facilities vs home with/without home health services). Results: Of the 122,604 patients surviving to discharge after emergent colectomy at 3012 hospitals, 46.7% were discharged to a nonhome destination. There was a wide variation in risk and reliability-adjusted nonhome discharge rates across hospitals (15% to 80%). Patients at hospitals in the highest quintile of nonhome discharge rates were more likely to have longer hospitalizations (15.1 vs 13.2; P < 0.001) and more complications (43.2% vs 34%; P < 0.001). On multivariable analysis, only hospital ownership of a skilled nursing facility (P < 0.001), teaching status (P = 0.025), and low nurse-to-patient ratios (P = 0.002) were associated with nonhome discharges. Conclusions: Nearly half of Medicare beneficiaries are discharged to a nonhome destination after emergent colectomy. Hospital ownership of a skilled nursing facility and low nurse-to-patient ratios are highly associated with nonhome discharges. This may signify the underlying financial incentives to preferentially utilize postacute care facilities under the traditional fee-for-service payment model. [ABSTRACT FROM AUTHOR]

Background: Trust in physicians is an essential part of therapeutic relationships. Complications are common after colorectal cancer procedures, but little is known of their effect on patient-surgeon relationships. We hypothesized that unexpected complications impair trust and communication between patients and surgeons. Methods: We performed a population-based survey of surgically diagnosed stage III colorectal cancer patients in the Surveillance Epidemiology and End Results registries for Georgia and Metropolitan Detroit between August 2011 and October 2012. Using published survey instruments, we queried subjects about trust in and communication with their surgeon. The primary predictor was the occurrence of an operative complication. We examined patient factors associated with trust and communication then compared the relationship between operative complications and patient-reported trust and communication with their surgeons. Results: Among 622 preliminary respondents (54% response rate), 25% experienced postoperative complications. Those with complications were less likely to report high trust (73% vs 81%, P = .04) and high-quality communication (80% vs 95%, P < .001). Complications reduced trust among only 4% of patient-surgeon dyads with high-quality communication, whereas complications diminished patients' trust in 50% with poorer communication (P < .001). After controlling for communication ratings, we found there was no residual effect of complications on trust (P = .96). Conclusion: Most respondents described trust in and communication with their surgeons as high. Complications were common and were associated with lower trust and poorer communication. However, the relationship between complications and trust was modified by communication. Trust remained high, even in the presence of complications, among respondents who reported high levels of patient-centered communication with their surgeons. [Copyright &y& Elsevier]

Objective: The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs. Study Design: We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article. Principal Findings: Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent. Conclusion: Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States. [Copyright &y& Elsevier]