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Background: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement., Objective: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons., Design: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates., Settings: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals., Patients: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons., Main Outcome Measures: Main outcome measures included 30-day risk-adjusted postoperative complications., Results: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41)., Limitations: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms., Conclusions: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo)., (Copyright © The ASCRS 2021.)

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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Both enhanced recovery and anesthesia literature recommend multimodal perioperative analgesia to hasten recovery, prevent adverse events, and reduce opioid use after surgery. However, adherence to, and outcomes of, these recommendations are unknown. We sought to characterize use of multimodal analgesia and its association with length of stay after colectomy., Materials and Methods: Within a statewide, 72-hospital collaborative quality initiative, we evaluated postoperative analgesia regimens among adult patients undergoing elective colectomy between 2012 and 2015. We used logistic regression to identify factors associated with the use of multimodal analgesia and performed multivariable linear regression to evaluate its association with postoperative length of stay (LOS)., Results: Among 7265 patients who underwent elective colectomy in the study period, 4660 (64.1%) received multimodal analgesia, 2405 (33.1%) received opioids alone, and 200 (2.8%) received one nonopioid pain medication alone. Multimodal analgesia was independently associated with shorter adjusted postoperative LOS, compared with opioids alone (5.60 d [95% CI 5.38-5.81] versus 5.96 d [5.68-6.24], P = 0.016)., Conclusions: Multimodal analgesia is associated with shorter LOS, yet one-third of patients statewide received opioids alone after colectomy. As surgeons increasingly focus on our role in the opioid crisis, particularly in postdischarge opioid prescribing, we must also focus on inpatient postoperative pain management to limit opioid exposure. At the hospital level, this may have the added benefit of decreasing LOS and hastening recovery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes., Objective: This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes., Design: This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome., Setting: January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative., Patients: A total of 2947 patients undergoing elective colectomy were selected., Main Outcome Measures: The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments., Results: The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04)., Limitations: This study focused on outcomes and did not consider processes of care as drivers of value., Conclusions: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMÍA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atención quirúrgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprensión de las interacciones entre el rendimiento clínico, utilización eficiente de los servicios y costos de los episodios quirúrgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomía sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago múltiple y resultados clínicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuación de valor (proporción de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el análisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clínico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 días, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomía electiva.Pagos por episodio de 30 días, ajustados al riesgo y estandarizados por precio.La tasa media de complicación ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pagó $3807 (17%) más que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) más altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centró en los resultados y no se consideraron a los procesos de atención, como impulsores de valor.En la colectomía electiva, los hospitales de alto valor logran pagos de episodios más bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, más allá que la reducción de complicaciones. Objetivos valiosos para optimizar el valor de la colectomía electiva, pueden incluir mejoras en los protocolos de recuperación, así como otras intervenciones que aumenten la eficiencia en todas las fases de la atención. Vea el resumen del video en http://links.lww.com/DCR/B56.

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.

Background: Although most surgical outcomes research focuses on clinical end points and complications, older adult patients may value functional outcomes more. However, little is known about the risk of long-term functional disability after colorectal procedures., Objective: The purpose of this research was to understand the incidence and likelihood of functional decline after high-risk (ie, ≥1% inpatient mortality) colorectal operations both without and with complications., Design: This was a retrospective matched cohort study., Settings: The Health and Retirement Study, a nationally representative, longitudinal survey of adults >50 years of age, collects data on functional status, cognition, and demographics, among other topics. The survey was linked with Medicare claims and National Death Index data from 1992 to 2012., Patients: Patients ≥65 years of age who underwent elective high-risk colorectal surgery with functional status measured before and after surgery were included. These patients were matched 1:3 to survey respondents who did not undergo major surgery, based on propensity scores., Main Outcome Measures: Functional decline, the primary outcome, was defined as an increase in the number of activities of daily living and instrumental activities of daily living requiring assistance before and after surgery. Using logistic regression, we examined whether surgery without or with complications was associated with functional decline., Results: We identified 289 patients who underwent high-risk colorectal surgery and 867 matched control subjects. Of the surgery patients, 90 (31%) experienced a complication. Compared with the control subjects, surgery patients experienced greater likelihood of functional decline (without complications: OR = 1.82 (95% CI, 1.22-2.71), and with complications: OR = 2.96 (95% CI, 1.70-5.14)). Increasing age also predicted greater odds of functional decline (OR = 2.09, per decade (95% CI, 1.57-2.80))., Limitations: The functional measures were self-reported by survey participants., Conclusions: High-risk colorectal surgery, without or with complications, is associated with increased likelihood of functional decline in older adults. Patient-centered decision-making should include discussion of expected functional outcomes and long-term disability. See Video Abstract at http://links.lww.com/DCR/B78. PÉRDIDA DE LA FUNCIONALIDAD A LARGO PLAZO LUEGO DE CIRUGÍA ELECTIVA COLORRECTAL DE ALTO RIESGO EN EL PACIENTE AÑOSO: Aunque en la mayoría de las investigaciones los resultados quirúrgicos se centran en los puntos finales clínicos y las complicaciones, actualmente se pueden valorar los resultados funcionales en el paciente añoso. Sin embargo, se sabe poco sobre el riesgo de la discapacidad funcional a largo plazo después de un procedimiento colorrectal.Comprender la incidencia y la probabilidad del deterioro funcional después de operaciones colorrectales de alto riesgo (es decir, ≥1% de mortalidad hospitalaria) con y sin complicaciones.Estudio de cohorte emparejado retrospectivo.El seguimiento longitudinal representativo a nivel nacional en adultos de >50 años y que recopila datos sobre su estado funcional, su estado cognitivo y su demografía, entre otros temas es el llamado "Estudio de Salud en jubilados." La encuesta se vinculó con los reclamos de Medicare y los datos del Índice Nacional de Defunciones entre 1992 y 2012.Aquellos de ≥65 años que se sometieron a cirugía colorrectal electiva de alto riesgo con un estado funcional medido antes y después de la cirugía. Estos pacientes se compararon 1: 3 con los encuestados que no se sometieron a cirugía mayor, según puntajes de propensión.La disminución functional como resultado primario, se definió como un aumento en el número de actividades de la vida diaria y actividades instrumentales de la vida diaria que requieren asistencia antes y después de la cirugía. Mediante la regresión logística, evaluamos si la cirugía sin complicaciones y/o con complicaciones se asoció con un deterioro funcional.Identificamos 289 pacientes que se sometieron a cirugía colorrectal de alto riesgo y 867 controles pareados. De los pacientes de cirugía, 90 (31%) experimentaron algun tipo de complicación. En comparación con los controles, los pacientes de cirugía experimentaron una mayor probabilidad de deterioro funcional (sin complicaciones: OR 1.82, IC 95% 1.22-2.71, y con complicaciones: OR 2.96, IC 95% 1.70-5.14). El aumento de la edad también predijo mayores probabilidades en el deterioro funcional (OR 2.09, por década, IC 95% 1.57-2.80).Las medidas funcionales fueron autoinformadas por los participantes de la encuesta.La cirugía colorrectal de alto riesgo, con o sin complicaciones, se asocia con una mayor probabilidad de deterioro funcional en adultos mayores. La toma de decisiones centradas en el paciente deben incluir la discusión de los resultados funcionales esperados y la discapacidad a largo plazo. Vea el resumen del video en http://links.lww.com/DCR/B78.

Background: Bundled payment programs broaden hospitals' responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare's Bundled Payments for Care Improvement - Advanced Model., Objective: This study aims to evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy., Design: This was a population-based study., Settings: We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014., Patients: We identified patients undergoing colon resections by using diagnosis-related group codes and International Classification of Diseases, Ninth Revision, Clinical Modification codes., Main Outcome Measures: We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010-2014).We projected per patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared savings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures., Results: Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of -$234 (95% CI, -$245 to -$223). Risk adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment, +$237; 95% CI, $96-$379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be -$472 (95% CI, -$506 to -$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI, $262-$326)., Limitations: Alternative payment models for colectomy have not yet been introduced., Conclusions: Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.

Background: Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home., Objective: We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection., Design: This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns., Settings: Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals., Patients: Patients undergoing colon and rectal resections were included., Main Outcome Measure: The main outcome measure was hospital use patterns of nonhome discharge., Results: Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045)., Limitations: This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size., Conclusions: This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

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.

Background: The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods., Study Design: This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm., Results: Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n = 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p = 0.0461) or MSQC models (0.77, p < 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p < 0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP., Conclusions: This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward or penalty., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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 compared mortality, 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 non-critical 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.

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 < .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 < .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 < .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 < .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.

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This article discusses the commonly encountered operative procedures of the colon and urinary diversions and provides a comprehensive review of indications, contraindications, surgical techniques with emphasis on normal and abnormal multimodality imaging findings.

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.

Purpose: Emerging evidence supporting the use of laparoscopic colectomy in patients with cancer has led to dramatic increases in utilization. Though certain patient and hospital characteristics may be associated with the use of laparoscopy, the influence of geography is poorly understood., Methods: We used national Medicare claims data from 2009 and 2010 to examine geographic variation in utilization of laparoscopic colectomy for patients with colon cancer. Patients were assigned to hospital referral regions (HRRs) where they were treated. Multivariable logistic regression was used to generate age, sex, and race-adjusted rates of laparoscopic colectomy for each HRR. Patient quintiles of adjusted HRR utilization were used to evaluate differences in patient and hospital characteristics across low and high-utilizing HRRs., Results: A total of 93,786 patients underwent colon resections at 3,476 hospitals during the study period, of which 30,502 (32.5%) were performed laparoscopically. Differences in patient characteristics between the lowest and highest quintiles of HRR utilization were negligible, and there was no difference in the availability of laparoscopic technology. Yet adjusted rates of laparoscopic colectomy utilization varied from 0% to 66.8% across 306 HRRs in the United States., Conclusion: There is wide geographic variation in the utilization of laparoscopic colectomy for Medicare patients with colon cancer, suggesting treatment location may substantially influence a patient's options for surgical approach. Future efforts to reduce variation will require increased dissemination of training techniques, novel opportunities for learning among surgeons, and enhanced educational resources for patients., (© 2014 by American Society of Clinical Oncology.)

Background: Patients with colorectal cancer (CRC) may suffer significant economic hardship during treatment. Complications are common after surgery for CRC and may exacerbate the financial burden of CRC even further., Methods: Within a population-based survey of patients with stage III CRC, the authors investigated the effects of disease and treatment on personal finances and computed a composite measure of financial burden. Correlations were examined between components of financial burden and patient-reported postoperative complications using chi-square analyses, and Mantel-Haenszel chi-square tend tests were used to evaluate correlations between composite financial burden scores and surgical complications, controlling for patient characteristics and other factors by using multivariable Poisson regression., Results: Among 937 respondents, 224 (24%) reported complications after surgery. Those with complications had significantly higher composite financial burden (P < .001 for trend): they were more likely to spend savings (40% vs 31%; P  = .01), borrow or take loans (18% vs 11%; P = .007), fail to make credit card payments (18% vs 11%; P = .005), reduce spending for food or clothes (38% vs 27%; P = .001), and decrease recreational activities (41% vs 33%; P = .03). They took significantly longer to return to work (P  = .009) and were more likely to experience significant worry about finances (61% vs 52%; P = .01)., Conclusions: Complications after surgery for CRC result in significant personal financial consequences as well as morbidity. Financial stress impairs quality of life and may prevent adherence to recommended treatments. Therefore, patients who suffer complications may require not just additional clinical care but also economic support and services., (© 2014 American Cancer Society.)

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 (<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.

Objective: To evaluate whether adherence to evidence-based best practices in colorectal surgery predicts improved postoperative outcomes., Summary and Background Data: Over a quarter of a million colon and rectal resections are performed annually in the United States. The average postoperative complication rate for these procedures approaches 30%., Methods: A panel of colorectal and general surgeons from 3 hospitals (1 academic medical center and 2 community hospitals) was assembled to ascertain a set of 37 evidence-based practices that they felt were the most pertinent to the evaluation and management of a patient undergoing a colorectal resection. Fifteen of these practices were classified as “key processes” for the prevention of complications. We then retrospectively reviewed medical records for 370 consecutive patients undergoing colorectal resection at these institutions. We evaluated the association of best-practice adherence to complications in the subset of patients with outcome data available through the American College of Surgeons National Surgical Quality Improvement Program., Results: Nonadherence rates exceeded 40% for 11 practices (including 2 key processes: avoidance of unnecessary blood transfusions and timely removal of central venous catheters). Among 198 patients with American College of Surgeons National Surgical Quality Improvement Program outcomes data, 38 (19%) experienced complications, of which 31 (82%) involved postoperative infection. Nonadherence to key-processes significantly predicted the occurrence of a complication (P = 0.002). Each additional process missed increased the odds of a postoperative complication by 60% (odds ratio: 1.6; 95% confidence interval: 1.2–2.2)., Conclusions: Failures of adherence with best practices in colorectal surgery is associated with an increased occurrence of complications. This study merits further research to confirm that improvement in compliance with perioperative best practices will reduce complication rates significantly.

PURPOSE: To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS: We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS: We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION: Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care. [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: Strong relationships between hospital volume and quality with inpatient surgery have prompted calls for volume-based referral. However, many are concerned that such policies would steer patients toward higher-cost hospitals. Study Design: Using 2005–2007 national Medicare claims, we identified all US hospitals performing elective colectomy for cancer, coronary artery bypass surgery, and abdominal aortic aneurysm repair. Patients were sorted into quintiles based on procedure volumes of the hospital in which they had surgery. For each quintile, we assessed overall 30-day Medicare episode payments adjusted for hospital case mix, including the index hospitalization, readmissions, physician services, and post-discharge ancillary care. Results: Hospitals in the lowest-volume quintile had considerably higher case-mix−adjusted episode payments than those in the highest-volume quintile for coronary artery bypass surgery ($960; 2.2% higher) and abdominal aortic aneurysm ($2,796; 8.5% higher), but differences were small for colectomy ($350; 1.3% higher). For coronary artery bypass surgery and abdominal aortic aneurysm repair, the index hospitalization was the largest source of higher overall payments at very low-volume hospitals. For all 3 procedures, very low-volume hospitals had higher payments for both 30-day readmissions and post-discharge ancillary care. Conclusions: Volume-based referral policies would not steer patients toward hospitals with high mean costs around episodes of inpatient surgery in the elderly. Minimizing the use of very low-volume hospitals has the potential to reduce costs as well as improve outcomes, particularly for operations with strong volume−outcomes associations. [ABSTRACT FROM AUTHOR]

The rising popularity of episode-based payment models for surgery underscores the need to better understand the drivers of variability in spending on postacute care. Examining postacute care spending for fee-for-service Medicare beneficiaries after three common surgical procedures in the period 2009-12, we found that it varied widely between hospitals in the lowest versus highest spending quintiles for postacute care, with differences of 129 percent for total hip replacement, 103 percent for coronary artery bypass grafting (CABG), and 82 percent for colectomy. Wide variation persisted after we adjusted for the intensity of postacute care. However, the variation diminished considerably after we adjusted instead for postacute care setting (home health care, outpatient rehabilitation, skilled nursing facility, or inpatient rehabilitation facility): It decreased to 16 percent for hip replacement, 4 percent for CABG, and 21 percent for colectomy. Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value postacute care setting. [ABSTRACT FROM AUTHOR]