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Objective: To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65. Data Sources: Health and Retirement Study survey data (1998-2018). Study Design: We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensityweighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility. Data Collection: Not applicable. Principal Findings: A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt. Conclusions: Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity. KEYWORDS caregiving, discontinuity, Medicare, stroke, surgery What is known * Family and friend care is received by millions of older Americans * Medicare spends $124 billion on surgical care, $30 billion on stroke care, and is known to increase the use of postacute services for new enrollees * Informal care can substitute for maintenance and well-being assistance requiring less skilled support What this study adds * Older Medicare beneficiaries receive substantial family and friend caregiving after acute health events * Medicare eligibility is associated with decreased informal caregiving use for those who experience a stroke * Ongoing restorative services for stroke patients may decrease the need for complementary support from family and friends, 1 | INTRODUCTION Each year, Medicare spends approximately $124 billion on surgical care, $30 billion on stroke care, and $60 billion on posthospital care. (1-4) It is well recognized that [...]

The management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal resection (APR) over low anterior resection (LAR) to optimize oncologic outcomes. This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer.

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In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency.

IMPORTANCE: The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. OBJECTIVE: To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. DESIGN, SETTING, AND PARTICIPANTS: This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. EXPOSURES: Receipt of robotic colectomy. MAIN OUTCOMES AND MEASURES: Incidence of postoperative medical and surgical complications and length of stay. RESULTS: A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). CONCLUSIONS AND RELEVANCE: While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

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IMPORTANCE: The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities. OBJECTIVES: To characterize hospitals’ readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation. DESIGN, SETTING, AND PARTICIPANTS: A total of 1315 American College of Surgeons Commission on Cancer–accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018. EXPOSURES: Hospitals’ readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards. MAIN OUTCOMES AND MEASURES: Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital. RESULTS: Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence. CONCLUSIONS AND RELEVANCE: Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.

Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs81.4%, P<0.01) and were more likely to have had surgery for cancer (22.9% vs48.5%, P<0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.

IMPORTANCE: Numerous study findings suggest that the use of laparoscopy is associated with lower health care costs for many operations, including colectomy. The extent to which these differences are due to the laparoscopic approach itself or selection bias from healthier patients undergoing the less invasive procedure is unclear. OBJECTIVE: To evaluate the differences in Medicare expenditures for laparoscopic and open colectomy. DESIGN, SETTING, AND PARTICIPANTS: A population-based study was conducted of Medicare beneficiaries undergoing laparoscopic or open colectomy between January 1, 2010, and December 31, 2012. The dates of the analysis were November 13 to December 10, 2016. Using instrumental variable methods to account for selection bias, actual Medicare payments after each procedure were evaluated. To identify the mechanisms of potential cost savings, the frequency and amount of physician, readmission, and postacute care payments were evaluated. Several sensitivity analyses were performed restricting the study population by patient demographic or surgeon specialty. MAIN OUTCOMES AND MEASURES: Actual Medicare expenditures up to 1 year after the index operation. RESULTS: The study population included 428 799 patients (mean [SD] age, 74 [10] years; 57.0% female). When using standard methods, patients undergoing laparoscopic colectomy (vs open) had lower total Medicare expenditures (mean, −$5547; 95% CI, −$5408 to −$5684; P &lt; .01). When using instrumental variable methods, which account for potentially unmeasured patient characteristics, patients undergoing laparoscopic colectomy (vs open) still had lower Medicare expenditures (mean, −$3676; 95% CI, −$2444 to −$4907; P &lt; .01), although the magnitude of the association was reduced. When examining the root causes of the difference in costs between patients who underwent laparoscopic and open colectomy, the key drivers were a reduction in costs from readmissions (mean, −$1102; 95% CI, −$1373 to −$831) and postacute care (mean, −$1446; 95% CI, −$1988 to −$935; P &lt; .01). CONCLUSIONS AND RELEVANCE: This population-based study demonstrates the influence of selection bias on cost estimates in comparative effectiveness research. While the use of laparoscopy reduced total episode payments, the source of savings is in the postacute care period, not the index hospitalization.

IMPORTANCE: Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons. OBJECTIVE: To assess rates of complications for MIC compared with OC among surgeons. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches. MAIN OUTCOMES AND MEASURES: Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC. RESULTS: Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P &lt; .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC. CONCLUSIONS AND RELEVANCE: Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

The recent national emphasis on improving value in healthcare delivery has placed increasing responsibility for health care value improvement on individual hospitals through financial incentives. Private Payer Initiatives are partnerships between providers and hospitals with payers that are intended to improve quality and value of health care. Blue Cross Blue Shield of Michigan has been a pioneer in the development and financial support of “The Michigan Model.” The Michigan Model is a is a longstanding multifaceted initiative that has successfully improved quality of healthcare delivery throughout the state through the development of collaborations between providers and acute care hospitals.

IMPORTANCE Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years. OBJECTIVES To review and classify the primary data published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis. EVIDENCE REVIEW We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines. FINDINGS We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (&lt;5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms. CONCLUSIONS AND RELEVANCE The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.

After a period of relatively slow uptake, laparoscopic colorectal surgery is now broadly implemented, and novel tools and approaches continue to be introduced into specialty practice. Oncological and functional outcomes of laparoscopic colectomy appear to be equivalent to those of open surgery. Laparoscopy offers short-term recovery benefits, including less pain, earlier return of bowel function, and shorter hospital stay. In certain settings, it may even reduce costs. Unfortunately, validated metrics of technical performance, to enable meaningful credentialing or detailed comparisons of techniques, are lacking. In this review, we discuss the best outcome data available, and suggest avenues for future assessment of technical quality in minimally invasive colorectal surgery.

The incidence of major complications after colorectal resection remains high. Rates may even exceed those predicted by risk-adjustment models commonly in use. Colon and rectal resections account for the greatest share of all postoperative morbidity and mortality in the National Surgical Quality Improvement Program general surgery cohort, and a disproportionate share of the costs associated with postoperative complications. Infectious complications are particularly overrepresented, as surgical site and urinary tract infections are 2-3 times more common after colon and rectal surgery than other general surgery operations. Thus, surgeons with a specialty interest in colorectal surgery may be flagged as “high outliers” unless more is done to account for procedure-specific risk.

Colorectal resections account for a disproportionate burden of morbidity within general surgery, and most major complications probably originate in the operating room. A number of intraoperative factors are known to contribute to outcomes in colorectal surgery and yet no generally accepted metrics exist to evaluate the safety and quality of intraoperative care. Some composite performance scores have been described but are not commonly in use. Experiences from other surgical specialties can inform future efforts to develop, validate, and implement intraoperative quality indicators for colorectal surgery.

OBJECTIVES To confirm the utility of a 10-point Surgical Apgar Score to rate surgical outcomes in a large cohort of patients. DESIGN Using electronic intraoperative records, we calculated Surgical Apgar Scores during a period of 2 years (July 1, 2003, through June 30, 2005). SETTING Major academic medical center. PATIENTS Systematic sample of 4119 general and vascular surgery patients enrolled in the National Surgical Quality Improvement Program surgical outcomes database at a major academic medical center. MAIN OUTCOME MEASURES Incidence of major postoperative complications and/or death within 30 days of surgery. RESULTS Of 1441 patients with scores of 9 to 10, 72 (5.0%) developed major complications within 30 days, including 2 deaths (0.1%). By comparison, among 128 patients with scores of 4 or less, 72 developed major complications (56.3%; relative risk, 11.3; 95% confidence interval, 8.6-14.8; P &lt; .001), of whom 25 died (19.5%; relative risk, 140.7; 95% confidence interval, 33.7-587.4; P &lt; .001). The 3-variable score achieves C statistics of 0.73 for major complications and 0.81 for deaths. CONCLUSIONS The Surgical Apgar Score provides a simple, immediate, objective means of measuring and communicating patient outcomes in surgery, using data routinely available in any setting. The score can be effective in identifying patients at higher- and lower-than-average likelihood of major complications and/or death after surgery and may be useful for evaluating interventions to prevent poor outcomes.Arch Surg. 2009;144(1):30-36--

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After technical errors, the most common cause of avoidable adverse events during inpatient surgical care is communication-related breakdowns. Lapses in communication have been associated with delays in care and increased patient morbidity. A previous study conducted at 4 academic medical centers examined surgical resident and attending surgeon communication practices and identified errors in communication for more than 30% of identified critical events. The data in that study also showed that residents and attending surgeons had not discussed the plan of care for 15% of randomly selected patients and that more than 20% of weekend patients had not been seen for more than 48 hours by an attending surgeon.

IMPORTANCE: As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. OBJECTIVE: To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. DESIGN, SETTING, AND PARTICIPANTS: This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals’ length of stay (LOS) mode were evaluated among a risk and postoperative complication–matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals’ mean surgical episode payments according to their change in LOS mode during the study period. EXPOSURE: Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. MAIN OUTCOMES AND MEASURES: Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. RESULTS: A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication–matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P &lt; .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P &lt; .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P &lt; .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. CONCLUSIONS AND RELEVANCE: Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.