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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 propensity‐weighted 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. [ABSTRACT FROM AUTHOR]

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

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

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

Background: A 10-point Surgical Apgar Score, based on patients' estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery, was developed to rate patients' outcomes in general and vascular surgery but has not been tested for patients having orthopaedic surgery. Questions/purposes: For patients undergoing hip and knee arthroplasties, we asked (1) whether the score provides accurate risk stratification for major postoperative complications, and (2) whether it captures intraoperative variables contributing to postoperative risk based on the three parameters independent of preoperative risk. Patients and Methods: We retrospectively reviewed the electronic records for all 3511 patients who underwent a hip or knee arthroplasty from March 2003 to August 2006 and extracted data to calculate a Surgical Apgar Score. We evaluated the relationship between scores and likelihood of major postoperative in-hospital complications and assessed its discrimination and calibration. Results: Complication rates increased monotonically as the score decreased. Even after controlling for preoperative risk, each 1-point decrease in the score was associated with a 34.0% increase (95% confidence interval, 0.66-0.84) in the odds of a complication. The overall discriminatory performance of the score was a c-statistic of 0.61. Seventy-six percent of all major complications occurred in patients classified as low risk with scores of 7 or greater. Conclusions: For patients undergoing hip and knee arthroplasties, the score captures important intraoperative information regarding risk of complications and contributes additional information to preoperative risk, but on its own is insufficient to provide comprehensive postoperative risk stratification for arthroplasties. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

This article discusses efforts to construct a model of the prevalence and distribution of surgical care on a global scale. This analysis took demographic data from World Health Organization (WHO) member states, governmental agencies, epidemiological organisations and per-head health spending analyses to estimate the total number of surgeries performed. Inequities in access to surgical care are noted. Efforts to collect information on the rates of death and complication from surgical procedures are also noted.

Background: Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient’s condition and chances of major complications or death. Study design: We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women’s Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution. Results: A 10-point score based on a patient’s estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score ≤ 4. Major complications or death occurred in 17 of these 29 patients (58.6%) within 30 days. By comparison, among 220 patients with scores of 9 or 10, only 8 (3.6%) experienced major complications or died (relative risk 16.1; 95% CI, 7.6–34.0; p < 0.0001). Conclusions: A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations. [Copyright &y& Elsevier]