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Objective: We review the existing research on environmentally sustainable surgical practices to enable SAO to advocate for improved environmental sustainability in operating rooms across the country. Summary of Background Data: Climate change refers to the impact of greenhouse gases emitted as a byproduct of human activities, trapped within our atmosphere and resulting in hotter and more variable climate patterns.1 As of 2013, the US healthcare industry was responsible for 9.8% of the country’s emissions2 ; if it were itself a nation, US healthcare would rank 13th globally in emissions.3 As one of the most energy-intensive and wasteful areas of the hospital, ORs drive this trend. ORs are 3 to 6 times more energy intensive than clinical wards.4 Further, ORs and labor/delivery suites produce 50%–70% of waste across the hospital.5,6 Due to the adverse health impacts of climate change, the Lancet Climate Change Commission (2009) declared climate change ‘‘the biggest global health threat of the 21st century’’ and predicted it would exacerbate existing health disparities for minority groups, children and low socioeconomic patients.7 Methods/Results: We provide a comprehensive narrative review of published efforts to improve environmental sustainability in the OR while simultaneously achieving cost-savings, and highlight resources for clinicians interested in pursuing this work. Conclusion: Climate change adversely impacts patient health, and disproportionately impacts the most vulnerable patients. SAO contribute to the problem through their resource-intensive work in the OR and are uniquely positioned to lead efforts to improve the environmental sustainability of the OR. [ABSTRACT FROM AUTHOR]

Background: Accurate risk estimation is essential when benchmarking surgical outcomes for reimbursement and engaging in shared decision-making. The greater complexity of emergency surgery patients may bias outcome comparisons between elective and emergency cases. Objective: To test whether an established risk modelling tool, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) predicts mortality comparably for emergency and elective cases. Methods: From the ACS-NSQIP 2011–2012 patient user files, we selected core emergency surgical cases also common to elective scenarios (gastrointestinal, vascular, and hepato-biliary-pancreatic). After matching strategy for Common Procedure Terminology (CPT) and year, we compared the accuracy of ACS-NSQIP predicted mortality probabilities using the observed-to-expected ratio (O:E), c-statistic, and Brier score. Results: In all, 56,942 emergency and 136,311 elective patients were identified as having a common CPT and year. Using a 1:1 matched sample of 37,154 emergency and elective patients, the O:E ratios generated by ACS-NSQIP models differ significantly between the emergency [O:E = 1.031; 95% confidence interval (CI) = 1.028–1.033] and elective populations (O:E = 0.79; 95% CI = 0.77–0.80, P < 0.0001) and the c-statistics differed significantly (emergency c-statistic = 0.927; 95% CI = 0.921–0.932 and elective c-statistic = 0.887; 95% CI = 0.861–0.912, P = 0.003). The Brier score, tested across a range of mortality rates, did not differ significantly for samples with mortality rates of 6.5% and 9% (eg, emergency Brier score = 0.058; 95% CI = 0.048–0.069 versus elective Brier score = 0.057; 95% CI = 0.044–0.07, P = 0.87, among 2217 patients with 6.5% mortality). When the mortality rate was low (1.7%), Brier scores differed significantly (emergency 0.034; 95% CI = 0.027–0.041 versus elective 0.016; 95% CI = 0.009–0.023, P value for difference 0.0005). Conclusion: ACS-NSQIP risk estimates used for benchmarking and shared decision-making appear to differ between emergency and elective populations. [ABSTRACT FROM AUTHOR]

Background: Effectiveness of carotid artery stenting (CAS) relative to carotid endarterectomy (CEA) among Medicare patients has not been established. We compared effectiveness of CAS versus CEA among Medicare beneficiaries.Methods and Results: We linked Medicare data (2000-2009) to the Society for Vascular Surgery's Vascular Registry (2005-2008) and the National Cardiovascular Data Registry's (NCDR) Carotid Artery Revascularization and Endarterectomy Registry (2006-2008/2009). Medicare patients were followed up from procedure date until death, stroke/transient ischemic attack, periprocedural myocardial infarction, or a composite end point for these outcomes. We derived high-dimensional propensity scores using registry and Medicare data to control for patient factors and adjusted for provider factors in a Cox regression model comparing CAS with CEA. Among 5254 Society for Vascular Surgery's Vascular Registry (1999 CAS; 3255 CEA) and 4055 Carotid Artery Revascularization and Endarterectomy Registry (2824 CAS; 1231 CEA) Medicare patients, CAS patients had a higher comorbidity burden and were more likely to be at high surgical risk (Society for Vascular Surgery's Vascular Registry: 96.7% versus 44.5%; Carotid Artery Revascularization and Endarterectomy Registry: 71.3% versus 44.7%). Unadjusted outcome risks were higher for CAS. Mortality risks remained elevated for CAS after adjusting for patient-level factors (hazard ratio, 1.24; 95% confidence interval, 1.06-1.46). After further adjustment for provider factors, differences between CAS and CEA were attenuated or no longer present (hazard ratio for mortality, 1.13; 95% confidence interval, 0.94-1.37). Performance was comparable across subgroups defined by sex and degree of carotid stenosis, but there was a nonsignificant trend suggesting a higher risk of adverse outcomes in older (>80) and symptomatic patients undergoing CAS.Conclusions: Outcomes after CAS and CEA among Medicare beneficiaries were comparable after adjusting for both patient- and provider-level factors. [ABSTRACT FROM AUTHOR]

Background--Clinical trials demonstrated the efficacy of carotid artery stenting (CAS) relative to carotid endarterectomy when performed by physicians with demonstrated proficiency. It is unclear how CAS performance may be influenced by the diversity in CAS and non-CAS provider volumes in routine clinical practice. Methods and Results--We linked Medicare claims to the Centers for Medicare and Medicaid Services' CAS Database (2005-2009). We assessed the association between 30-day mortality and past-year physician (0, 1-4, 5-9, 10-19, ≥20) and hospital (<10, 10-19, 20-39, ≥40) CAS volumes and past-year hospital coronary and peripheral stenting volumes (<200, 200-399, 400-849, ≥850) among beneficiaries at least 66 years of age. Unadjusted 30-day mortality risk was 1.8% (95% confidence interval [CI], 1.6-2.0) for 19 724 patients undergoing CAS by 2045 physicians in 729 hospitals. Median past-year CAS volume was 9 (interquartile range, 4-19) for physicians and 23 (interquartile range, 12-41) for hospitals. Compared to physicians performing ≥20 CAS in the past year, lower CAS volumes were associated with higher adjusted risks of 30-day morality (P value for trend < 0.05): 1.4 (95% CI, 0.9-2.3) for 0 past-year CAS, 1.3 (95% CI, 0.9-1.8) for 1 to 4, 1.1 (95% CI, 0.8-1.6) for 5 to 9, and 0.9 (95% CI, 0.7-1.4) for 10 to 19. An inverse relationship between 30-day mortality and past-year CAS hospital volume as well as past-year hospital non-CAS volume, past-year hospital non-CAS volume, and 30-day mortality was also noted. Conclusions--Among Medicare patients, an inverse relationship exists between physician and hospital CAS volumes and hospital non-CAS stenting volume and 30-day mortality, even after adjusting for all pertinent patient- and hospital-level factors. [ABSTRACT FROM AUTHOR]

Background: Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists., Methods: We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream., Results: Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards., Conclusions: Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.

Objective: To evaluate the impact of market competition on patient mortality and graft failure after kidney transplantation., Background: Kidneys are initially allocated within 58 donation service areas (DSAs), which have varying numbers of transplant centers. Market competition is generally considered beneficial., Methods: The Scientific Registry of Transplant Recipients database was queried and the Herfindahl-Hirschman index (HHI), a measure of market competition, was calculated for each DSA from 2003 to 2012. Receipt of low-quality kidneys (Kidney Donor Profile Index ≥ 85) was modeled with multivariable logistic regression, and Cox proportional hazards models were created for graft failure and patient mortality., Results: A total of 127,355 adult renal transplants were performed. DSAs were categorized as 7 no (HHI = 1), 17 low (HHI = 0.52-0.97), 17 medium (HHI = 0.33-0.51), or 17 high (HHI = 0.09-0.32) competition. For deceased donor kidney transplantation, increasing market competition was significantly associated with mortality [hazard ratio (HR): 1.11, P = 0.01], graft failure (HR: 1.18, P = 0.0001), and greater use of low-quality kidneys (odds ratio = 1.39, P < 0.0001). This was not true for living donor kidney transplantation (mortality HR: 0.94, P = 0.48; graft failure HR: 0.99, P = 0.89). Competition was associated with longer waitlists (P = 0.04) but not with the number of transplants per capita in a DSA (P = 0.21)., Conclusions: Increasing market competition is associated with increased patient mortality and graft failure and the use of riskier kidneys. These results may represent more aggressive transplantation and tolerance of greater risk for patients who otherwise have poor alternatives. Market competition should be better studied to ensure optimal outcomes.