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Background: Shared decision making and patient‐centred communication have become part of pre‐procedural decisions and perioperative care across medical specialties. However, gaps exist in patient communication about the implanted device received and the benefits in sharing information about their procedure and device. Objective: To understand the patients' knowledge of identifying information for their implanted devices and perspectives on sharing their implanted device information. Methods: Four focus groups were conducted with patients who had received a cardiac or vascular implanted device from one of the study sites within the previous 6 months. Data were transcribed and thematically analysed. Results: Five themes emerged: lack of awareness of identifying information on implanted devices; value of information on implanted devices; varying trust with sharing device information; perceived risk with sharing device information; and lack of consensus on a systematic process for tracking implanted devices. Discussion: Patients desire post‐procedural information on their implanted device and a designated plan for longitudinal follow‐up, but lack trust and perceive risk with broadly sharing their implanted device information. Conclusion: After receiving an implanted device, post‐procedural patient communication needs to be expanded to include identifying information on the device including the unique device identifier, how long‐term tracking will be supported and the process for notification in case of a problem with the device. This communication should also include education on how sharing device information supports patients' long‐term health care, post‐market safety surveillance and research. Patient or Public Contribution: The research team included members who were also patients with implanted devices. [ABSTRACT FROM AUTHOR]

Background: This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS).Methods: Data for fiscal years 2007 - 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF.Results: Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas.Conclusions: In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare. [ABSTRACT FROM AUTHOR]

In this paper the authors begin an exploration of newly collected data on the health conditions and disability benefits of Union Army veterans and make comparisons to recipients of disability benefits in more recent times. The authors find two main results. The first is that there has been a significant shift in the types of diseases that lead to disability, both in terms of prevalence rates and benefit levels. The second is more surprising: the disabled in modern times generally have a greater number of chronic illnesses than did disabled Union Army veterans, even those who were severely disabled. This result implies a way of thinking about disease and disability that deserves more research attention. In short, prior to the advent of modern medicine and the concurrent reductions in the physical demands of work, people became disabled not because they had numerous chronic illnesses (i.e., high rates of co-morbidity), but because individual conditions (even ones as simple as hernias or hemorrhoids) had much more severely debilitating effects on health and upon the capacity to work than those same conditions do today. [ABSTRACT FROM AUTHOR]

The author reflects on health-related quality of life (HRQoL) in the U.S. He states that assessing changes in HRQoL allows health personnel to measure a more comprehensive outcome that reflects a patient. He cites that HRQoL has been used as predicator of outcomes, specially survival, in patients with coronary heart disease. He cites that health personnel must incorporate measure of HRQoL to their clinical research designs to analyze composite outcomes relevant to the patient's perspective

Background: Confounding by indication is a serious threat to comparative studies using real world data. We assessed the utility of automated data-adaptive analytic approach for confounding adjustment when both claims and clinical registry data are available., Methods: We used a comparative study example of carotid artery stenting (CAS) vs. carotid endarterectomy (CEA) in 2005-2008 when CAS was only indicated for patients with high surgical risk. We included Medicare beneficiaries linked to the Society for Vascular Surgery's Vascular Registry >65 years old undergoing CAS/CEA. We compared hazard ratios (HRs) for death while adjusting for confounding by combining various 1) Propensity score (PS) modeling strategies (investigator-specified [IS-PS] vs. automated data-adaptive [ada-PS]); 2) data sources (claims-only, registry-only and claims-plus-registry); and 3) PS adjustment approaches (matching vs. quintiles-adjustment with/without trimming). An HR of 1.0 was used as a benchmark effect estimate based on CREST trial., Results: The cohort included 1,999 CAS and 3,255 CEA patients (mean age 76). CAS patients were more likely symptomatic and at high surgical risk, and experienced higher mortality (crude HR = 1.82 for CAS vs. CEA). HRs from PS-quintile adjustment without trimming were 1.48 and 1.52 for claims-only IS-PS and ada-PS, 1.51 and 1.42 for registry-only IS-PS and ada-PS, and 1.34 and 1.23 for claims-plus-registry IS-PS and ada-PS, respectively. Estimates from other PS adjustment approaches showed similar patterns., Conclusions: In a comparative effectiveness study of CAS vs. CEA with strong confounding by indication, ada-PS performed better than IS-PS in general, but both claims and registry data were needed to adequately control for bias., Competing Interests: HK and HM are affiliated with the department of Healthcare Quality Assessment, University of Tokyo, which is a social collaboration department supported by the National Clinical Database, Johnson & Johnson KK, and Nipro Corporation. HK has received lecture fees from Chugai Pharmaceutical Co., Ltd., Johnson & Johnson KK, and consultancy fees from Mitsubishi Tanabe Pharm and EP Croit Co., Ltd. JJJ is a full-time employee of Regeneron Pharmaceuticals. This study was conducted prior to her employment at the company. SS has served as a member of the US FDA advisory committee and as a consultant for Pfizer Inc., Medtronic, and Merck. SS has also received research funding from the National Institutes of Health, the Cystic Fibrosis Foundation, Pfizer Inc., and Bristol-Myers Squibb. All other authors have no conflicts to declare. The above do not alter our adherence to Plos One policies on sharing data and materials.

Background: In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a potent method to monitor implanted devices, yet implementation has lagged because of questions of benefit and operational concerns., Methods: To illustrate the potential benefit of including DIs in claims, rates of 90-day adverse events after implantation using an electronic health record (EHR) were compared with the EHR plus claims, which capture utilization outside that EHR's health system. To explore operations, we planned a pilot project to transmit the DI of implanted devices from the point of care to the claim at two provider/payer pairs., Results: By querying claims plus EHR, estimated rates of patients with potential adverse events were as much as 3.75 times higher. For our pilot, our multistakeholder team identified and resolved the following five challenges: (1) capturing the DI at the point of care; (2) selecting a location for the DI on the claim form; (3) transmitting the DI to the claim form; (4) analyzing the claim forms received by the payer; and (5) verifying the quality of the transmitted information., Conclusions: Including DIs on claims could allow more complete data capture of adverse events for implanted devices than the EHR data. We overcame challenges in transmitting the DI to the claim with attention to planning and multistakeholder involvement., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Preoperative magnetic resonance imaging (MRI) utilization in breast cancer treatment has increased significantly over the past 2 decades, but its use continues to have interprovider variability and disputed clinical indications., Objective: The aim of this study was to evaluate non-clinical factors associated with preoperative breast MRI utilization., Methods: This study utilized TRICARE claims data from 2006 to 2015. TRICARE provides health benefits for active duty service members, retirees, and their dependents at both military (direct care with salaried physicians) and civilian (purchased care under fee-for-service structure) facilities. We studied patients aged 25-64 years with a breast cancer diagnosis who had undergone mammogram/ultrasound (MMG/US) alone or with subsequent breast MRI prior to surgery. Facility characteristics included urban-rural location according to the National Center for Health Statistics classification. Adjusted multivariable logistic regression tests were used to identify independent factors associated with preoperative breast MRI utilization., Results: Of the 25,392 identified patients, 64.7% (n = 16,428) received preoperative MMG/US alone, while 35.3% (n = 8964) underwent additional MRI. Younger age, Charlson Comorbidity Index score ≥ 2, active duty or retired beneficiary category, officer rank (surrogate for socioeconomic status), Air Force service branch, metropolitan location, and purchased care were associated with an increased likelihood of preoperative MRI utilization. Non-metropolitan location and Navy service branch were associated with decreased MRI use., Conclusion: After controlling for expected clinical risk factors, patients were more likely to receive additional MRI when treated at metropolitan facilities or through the fee-for-service system. Both associations may point toward non-clinical incentives to perform MRI in the treatment of breast cancer.

Background: Epidural analgesia (EA) is frequently used as an adjuvant to general anesthesia (GA) for improved postoperative analgesia and reduced rates of cardiac, pulmonary, and renal complications. However, only a few studies have examined EA-GA specifically during open abdominal aortic aneurysm (AAA) repair. The effects of EA-GA specifically during open AAA repair regarding postoperative outcomes are unknown. This study was performed to evaluate postoperative outcomes in patients undergoing open AAA repair with EA-GA versus GA alone., Methods: We performed a retrospective analysis for patients undergoing surgery between January 1, 2014 and December 31, 2016 using the National Surgical Quality Improvement Program (NSQIP) database. Propensity score matching was used to establish cohorts for analysis. Multivariable logistic regression was performed to determine significant perioperative outcomes for each anesthesia type. A total of 2,171 patients underwent open AAA repair in our date range; we excluded emergent and ruptured AAA. A total of 2,145 patients were included in our analysis, of whom 653 patients received EA-GA and 1,492 patients received GA only., Results: Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes included hospital length of stay, return to the operating room, and readmission. Patients in EA + GA and GA alone groups were comparable regarding demographics, functional status, and comorbidities. Decreased odds of readmission was observed in EA + GA compared with GA (0.49, 95% CI [0.28-0.86]; P = 0.014); and increased odds of receiving a blood transfusion was observed in those who underwent EA + GA (1.63, 95% CI [1.23-2.14]; P = 0.001). No difference was observed between patients who had an AAA repair with EA + GA versus GA alone with regard to mortality, return to operating room, major pulmonary, cardiac, renal, or infectious complications., Conclusions: EA + GA was not associated with decreased mortality or decreased rates of major postoperative pulmonary, cardiac, or renal complications. EA + GA was associated with increased transfusion requirements and decreased rates of hospital readmission., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Index length of stay (LOS) and readmissions are viewed as important quality measures. However, these metrics represent competing demands as an inordinate reduction in LOS may lead to unplanned readmissions. We sought to assess the optimal LOS associated with the lowest 90-d readmission rate following discharge after common surgical procedures., Materials and Methods: This was a retrospective study relying on Tricare claims. We identified all eligible adult patients (18-64 y) receiving a series of common surgical procedures between 2006 and 2014. We used a generalized additive model with spline regression to determine the optimal LOS associated with the lowest 90-d risk of readmission., Results: Ninety-day readmission rates varied from 6.03% to 34.69%. Most procedures exhibited a logit linear relationship, with the lowest risk of readmission evident on postoperative day-1 and increasing thereafter. Among the more invasive procedures (e.g., esophagectomy and radical cystectomy), a U-shaped relationship was realized, indicating that expedited discharge would increase the potential for readmission as would any extended hospital LOS. For these procedures, the ideal index LOS appeared to be 6-7 d for radical cystectomy and 12-13 d for esophagectomy., Conclusions: Our results support the practice of discharging patients as soon as clinically feasible after hip and knee arthroplasty, lumbar spine surgery, hernia repair, appendectomy, nephrectomy, and colectomy. Among esophagectomy or radical cystectomy, there is a well-defined optimal index admission period and discharge outside this window appears to be detrimental. Our results suggest that invasive procedures appear to possess a unique "signature" when it comes to optimal LOS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients., Methods: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression., Results: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened., Conclusion: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities., (© 2018 American Cancer Society.)

Importance: The overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery., Objectives: To describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills., Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing., Exposures: Length of initial prescription for opioid pain medication., Main Outcomes and Measures: Need for an additional subsequent prescription for opioid pain medication, or a refill., Results: Of the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women's health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%)., Conclusions and Relevance: Ideally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women's health procedures, and 6 to 15 days for musculoskeletal procedures.

Objectives: To compare geographic variation in healthcare spending and utilization between the Military Health System (MHS) and Medicare across hospital referral regions (HRRs)., Study Design: Retrospective analysis., Methods: Data on age-, sex-, and race-adjusted Medicare per capita expenditure and utilization measures by HRR were obtained from the Dartmouth Atlas for 2007 to 2010. Similarly, adjusted data from 2007 and 2010 were obtained from the MHS Data Repository and patients assigned to HRRs. We compared high- and low-spending regions, and computed coefficient of variation (CoV) and correlation coefficients for healthcare spending, hospital inpatient days, hip surgery, and back surgery between MHS and Medicare patients., Results: We found significant variation in spending and utilization across HRRs in both the MHS and Medicare. CoV for spending was higher in the MHS compared with Medicare, (0.24 vs 0.15, respectively) and CoV for inpatient days was 0.36 in the MHS versus 0.19 in Medicare. The CoV for back surgery was also greater in the MHS compared with Medicare (0.47 vs 0.29, respectively). Per capita Medicare spending per HRR was significantly correlated to adjusted MHS spending (r = 0.3; P <.0001). Correlation in inpatient days (r = 0.29; P <.0001) and back surgery (r = 0.52; P <.0001) was also significant. Higher spending markets in both systems were not comparable; lower spending markets were located mostly in the Midwest., Conclusions: In comparing 2 systems with similar pricing schemes, differences in spending likely reflect variation in utilization and the influence of local provider culture.

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.

Background: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care., Methods: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care., Results: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race., Conclusions: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values., Level of Evidence: Prognostic and epidemiologic study, level III.

Background: Kidney transplant centers are distributed unevenly throughout 58 donor service areas (DSAs) in the United States. Market competition and transplant center density may affect transplantation access and outcomes. We evaluated the role of spatial organization of transplant centers in conjunction with market competition in the conduct of kidney transplantation., Methods: The Scientific Registry of Transplant Recipients was queried for market characteristics associated with kidney transplantation between 2003 and 2012. Market competition was calculated using the Herfindahl Hirschman Index. Kidney transplant centers were geocoded to measure spatial organization by the average nearest neighbor (ANN) method. Kidney quality was assessed by kidney donor risk index. A hierarchical negative binomial mixed effects model tested the relationship between market characteristics and annual kidney transplants by DSA., Results: About 152,071 kidney transplants were performed at 229 adult kidney transplant centers in 58 DSAs. Greater market competition was associated with kidney transplant center spatial clustering (P < 0.001). In multivariable analysis, more kidney transplant centers (incidence rate ratio [IRR], 1.04; P = 0.005), 100 more new listings (IRR, 1.02; P = 0.003), 100 more deceased donors (IRR, 1.23; P < 0.001), 100 more new dialysis registrants (IRR, 1.01; P < 0.001), and higher kidney donor risk index (IRR, 1.98; P < 0.001) were associated with increased kidney transplants., Conclusions: After controlling for market characteristics, larger numbers of kidney transplant centers were associated with more kidney transplants and increased utilization of deceased donor kidneys. This underlines the importance of understanding geography as well as competition in improving access to kidney transplantation.

Background: Liver transplantation centers are unevenly distributed within the Donor Service Areas (DSAs) of the United States. This study assessed how market competition and liver transplantation center density are associated with liver transplantation volume within individual DSAs., Study Design: We conducted a retrospective cohort study of 53,156 adult liver transplants in 45 DSAs with 110 transplantation centers identified from the Scientific Registry of Transplant Recipients between 2003 and 2012. The following measures were derived annually for each DSA: market competition using the Herfindahl Hirschman Index, transplantation center density by the Average Nearest Neighbor method, liver quality by the Liver Donor Risk Index, and patient risk by the Model for End-Stage Liver Disease. A hierarchical mixed effects negative binomial regression model of the relationship between liver transplants and market factors was created annually. Patient and graft survival were investigated with a Cox proportional hazards model., Results: Transplantation center density was associated with market competition (p < 0.0001), listings for organ transplantation (p < 0.0001), and Model for End-Stage Liver Disease at transplantation (p = 0.0005). More liver transplantation centers (incidence rate ratio [IRR] = 1.03; p = 0.04), greater market competition (IRR = 1.36; p = 0.02), increased listings (IRR = 1.14; p < 0.0001), more donors (IRR = 1.24; p < 0.0001), and higher Liver Donor Risk Index (IRR = 3.35; p < 0.0001) were associated with more transplants. No market variables were associated with increased mortality after transplantation., Conclusions: After controlling for demographic and market factors, a greater concentration of centers was associated with more liver transplants without impacting overall survival. These results warrant additional investigation into the relationship between geospatial factors and liver transplantation volume with consideration for the optimization of scarce resources., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Failure-to-rescue (FTR or death after postoperative complication) is thought to explain surgical mortality excesses across hospitals, and FTR is an emerging performance measure and target for quality improvement. We compared the FTR population to preoperatively identifiable subpopulations for their potential to close the mortality gap between lowest- and highest-mortality hospitals., Study Design: Patients undergoing small bowel resection, pancreatectomy, colorectal resection, open abdominal aortic aneurysm repair, lower extremity arterial bypass, and nephrectomy were identified in the 2007 to 2011 Nationwide Inpatient Sample. Lowest- and highest-mortality hospitals were defined using risk- and reliability-adjusted mortality quintiles. Five target subpopulations were established a priori: the FTR population, predicted high-mortality risk (predicted highest-risk quintile), emergency surgery, elderly (>75 years old), and diabetic patients., Results: Across the lowest mortality quintile (n=282 hospitals, 56,893 patients) and highest-mortality quintile (282 hospitals, 45,784 patients), respectively, the size of target subpopulations varied only for the FTR population (20.2% vs 22.4%, p=0.002) but not for other subpopulations. Variation in mortality rates across lowest- and highest-mortality hospitals was greatest for the high-mortality risk (7.5% vs 20.2%, p<0.0001) and FTR subpopulations (7.8% vs 18.9%, p<0.0001). The FTR and high-risk populations had comparable sensitivity (81% and 75%) and positive predictive value (19% and 20%, respectively) for mortality. In Monte Carlo simulations, the mortality gap between the lowest- and highest-mortality hospitals was reduced by nearly 75% when targeting the FTR population or the high-risk population, 78% for the emergency surgery population, but less for elderly (51%) and diabetic (17%) populations., Conclusions: Preoperatively identifiable patients with high estimated mortality risk may be preferable to the FTR population as a target for surgical mortality reduction., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the timing and relative frequency of common postoperative complications in a contemporary, diverse surgical population and develop a mnemonic for teaching and clinical decision support., Patients and Methods: We enrolled a cohort of general and vascular surgical patients undergoing elective, inpatient surgery in the American College of Surgeons National Surgical Quality Improvement Program database between 2005 and 2011. Index complications were noted by postoperative day (POD). Timing and incidence were compared within each day., Results: Among 614,525 patients, 51,173 (9.88%) experienced the following index complications over 30 days: pneumonia (n = 5947), urinary tract infection (n = 9459), superficial surgical site infection (sSSI) (n = 20,460), deep/organ space surgical site infection (dSSI) infection (n = 11,847), venous thromboembolism (n = 4478), kidney injury (n = 2620), and myocardial infarction (n = 1813). Median time to complication differed significantly for index complications (p < 0.0001). On POD 0, the most common complication was myocardial infarction (incidence 4.26/10,000 patient days; 95% CI: 3.75-4.78). On POD 1 and 2, pneumonia was the most common complication, with peak incidence on POD 2 (20.36; 95% CI: 19.22-21.51). On POD 3, pneumonia (16.3; 95% CI: 15.27-17.33) and urinary tract infection (15.5; 95% CI: 14.49-16.51) were significantly more common than other complications. On POD 4, the most common complication was sSSI (16.24; 95% CI: 15.20-17.28). From POD 5 to POD 30, sSSI and dSSI were the 2 most common complications. Risk of venous thromboembolism declined only slightly through POD 30., Conclusion: We propose a mnemonic for postoperative complication timing and frequency, independent of fever, as follows: Waves (myocardial infarction), Wind (pneumonia), Water (urinary tract), Wound (sSSI and dSSI), and Walking (venous thromboembolism) in the order of likelihood., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to examine variation in outcomes for patients receiving carotid artery stenting (CAS) across a sample of U.S. hospitals and assess the extent to which this variation was attributable to differences in case mix and procedural volume., Background: As CAS is increasingly being used throughout the United States, assessing hospital variation in CAS outcomes is critical to understanding and improving the quality of care for patients with carotid artery disease., Methods: Hospitals participating in the National Cardiovascular Data Registry-Carotid Artery Endarterectomy and Revascularization Registry contributing more than 5 CAS procedures from 2005 through 2013 were eligible for inclusion. We estimated unadjusted and risk-standardized rates of in-hospital stroke or death for each participating hospital using a previously validated prediction model and applying hospital-level random effects., Results: There were 188 hospitals contributing 19,381 CAS procedures during the period of interest. Unadjusted and risk-standardized in-hospital stroke or death rates ranged from 0% to 18.8% and 1.2% to 4.7%, respectively. Operator and hospital volumes were not significant predictors of outcomes after adjustment for case mix (p = 0.15 and p = 0.09, respectively)., Conclusions: CAS outcomes vary 4-fold among hospitals, even after adjustment for differences in case mix. Future work is needed to identify the sources of this variation and develop initiatives to improve patient outcomes., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: After the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and carotid endarterectomy (CEA) decreased. We evaluated trends in surgeons' past-year CEA case-volume and 30-day mortality after CEA, and their association before and after the National Coverage Determination., Methods: In a retrospective cohort study of patients undergoing CEA (2001-2008) and CAS (2005-2008) using Medicare data, we described yearly trends of CEA and CAS rates, patient characteristics, and 30-day mortality after CEA. We used logistic regression adjusting for patient- and surgeon-level factors to assess the effect of surgeon case volume on 30-day mortality after CEA., Results: We identified 454 717 CEA and 27 943 CAS patients. Patients undergoing CEA in recent years were older and had more comorbidities than earlier years. CEA rates per 10 000 beneficiaries declined from 18.1 in 2002 to 12.7 in 2008, whereas median surgeon past-year case-volume declined from 27 to 21. The CAS rates peaked at 2.3 per 10 000 beneficiaries in 2006 but declined to 1.8 in 2008, resulting in declining overall revascularization procedure rates during 2005 to 2008. Thirty day post-CEA mortality was 1.40% (95% confidence interval, 1.34-1.47) in 2001 to 2002 and 1.17% (1.10-1.24) in 2007 to 2008. Surgeon's past-year case-volume of <10 was associated with higher 30-day mortality consistently during 2001 to 2008., Conclusions: The rate of CEA procedures decreased substantially during 2001 to 2008, as did surgeon past-year case-volume. The postprocedural mortality in Medicare beneficiaries was high compared with trial patients but somewhat improved over time. Those operated by lower past-year case-volume surgeons had increased mortality., (© 2015 American Heart Association, Inc.)

Importance: Despite increased carotid artery stenting (CAS) dissemination following the 2005 National Coverage Determination, to our knowledge, periprocedural and long-term outcomes have not been described among Medicare beneficiaries., Objective: To describe the incidence of outcomes during and after the periprocedural period among Medicare beneficiaries undergoing CAS., Design, Setting, and Participants: Observational study with a mean follow-up time of approximately 2 years among 22,516 fee-for-service Medicare beneficiaries at least 66 years old undergoing CAS (2005-2009) who were linked to the Centers for Medicare & Medicaid Services' CAS database. Database procedure dates were required to fall during a Medicare hospitalization for CAS., Main Outcomes and Measures: Periprocedural (30-day) and long-term risks of mortality and stroke or transient ischemic attack, as well as periprocedural myocardial infarction. Subgroups were based on sociodemographic, clinical, and center-level factors, as well as the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial or Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) enrollment criteria., Results: The mean patient age was 76.3 years, 60.5% were male, 93.8% were of white race, 91.2% were at high surgical risk, 47.4% were symptomatic, and 97.4% had carotid stenosis of at least 70%. Crude 30-day mortality, stroke or transient ischemic attack, and myocardial infarction risks were 1.7% (95% CI, 1.5%-1.8%), 3.3% (95% CI, 3.0%-3.5%), and 2.5% (95% CI, 2.3%-2.7%), respectively. Mortality during a mean follow-up time of 2 years was 32.0% (95% CI, 31.0%-33.0%), with rates of 37.3% (95% CI, 35.8%-38.7%) among symptomatic patients and 27.7% (95% CI, 26.4%-28.9%) among asymptomatic patients. Older age, symptomatic carotid stenosis, and nonelective hospital admission were associated with increased adjusted hazards of mortality and stroke or transient ischemic attack during and after the periprocedural period. The presence of a stroke center, government ownership, and a hospital bed capacity of 500 or more were associated with increased adjusted hazards of periprocedural mortality and stroke or transient ischemic attack. Few patients met the SAPPHIRE trial or CREST enrollment criteria primarily because physicians did not meet proficiency requirements either due to exceeding periprocedural complication trial thresholds or not meeting minimum CAS volume requirements., Conclusions and Relevance: Competing risks may limit the benefits of CAS in certain Medicare beneficiaries, particularly among older and symptomatic patients who have higher periprocedural and long-term mortality risks. The generalizability of trials like the SAPPHIRE or CREST to the Medicare population may be limited, underscoring the need to evaluate real-world effectiveness of carotid stenosis treatments.

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.

Background: Performance measurement has become central to surgical practice. We systematically reviewed all endorsed performance measures from the National Quality Forum, the national clearing house for performance measures in health care, to identify measures relevant to surgical practice and describe measure stewardship, measure types, and identify gaps in measurement., Study Design: Performance measures current to June 2014 were categorized by denominator statement as either assessing surgical practice in specific or as part of a mixed medical and surgical population. Measures were further classified by surgical specialty, Donabedian measure type, patients, disease and events targeted, reporting eligibility, and measure stewards., Results: Of 637 measures, 123 measures assessed surgical performance in specific and 123 assessed surgical performance in aggregate. Physician societies (51 of 123, 41.5%) were more common than government agencies (32 of 123, 26.0%) among measure stewards for surgical measures, in particular, the Society for Thoracic Surgery (n = 32). Outcomes measures rather than process measures were common among surgical measures (62 of 123, 50.4%) compared with aggregate medical/surgical measures (46 of 123, 37.4%). Among outcomes measures, death alone was the most commonly specified outcome (24 of 62, 38.7%). Only 1 surgical measure addressed patient-centered care and only 1 measure addressed hospital readmission. We found 7 current surgical measures eligible for value-based purchasing., Conclusions: Surgical society stewards and outcomes measure types, particularly for cardiac surgery, were well represented in the National Quality Forum. Measures addressing patient-centered outcomes and the value of surgical decision-making were not well represented and may be suitable targets for measure innovation., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Objective: Open surgical reconstruction for supra-aortic trunk occlusive disease persists despite advances in endovascular therapy. Although extrathoracic reconstructions developed as a safer alternative to transthoracic reconstructions, contemporary national data evaluating relative rates of operative outcomes are lacking., Methods: With use of the National Surgical Quality Improvement Program (2005-2011), patients who underwent transthoracic or extrathoracic reconstruction were evaluated. Patients with nonocclusive indications were excluded. The primary outcome was a composite end point of stroke/myocardial infarction (MI)/death. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed., Results: Overall, 83 patients (10.7%) underwent transthoracic reconstructions and 692 patients (89.3%) underwent extrathoracic reconstructions. Vascular surgeons performed most transthoracic (96%) and extrathoracic (97%) reconstructions. The most common extrathoracic reconstructions were carotid-subclavian bypass (68%), carotid-carotid bypass (14%), and subclavian transposition (7%). Less commonly, axillary-axillary bypass (6%), subclavian-axillary bypass (2%), subclavian-subclavian bypass (1%), and carotid transposition (1%) were performed. At the time of operation, 10% (transthoracic reconstructions) and 8% (extrathoracic reconstructions) of patients had a concurrent carotid endarterectomy (P < .60). Analysis of more than 20 characteristics showed that the groups did not differ significantly. The two groups had similar rates of postoperative stroke (1.2% in the transthoracic reconstruction group vs 2.2% in the extrathoracic reconstruction group; P > .99), MI (0% vs 1.3%; P = .61), death (2.4% vs 1.3%; P = .33), and stroke/MI/death (3.6% vs 3.8%; P > .99). Transthoracic reconstruction patients had longer hospital stays (6.3 days vs 4.0 days; P < .0002), received more transfusions (8.4% vs 2.5%; P < .0096), and had higher rates of postoperative sepsis (3.6% vs 0.3%; P < .01) and venous thromboembolic complications (3.6% vs 0.4%; P < .02). After adjustment for other factors, including surgical approach, stroke/MI/death was significantly associated with postoperative pneumonia (odds ratio [OR], 26.0; 95% confidence interval [CI], 6.29-108.28; P < .0001), postoperative ventilator dependence (OR, 12.45; 95% CI, 2.74-56.48; P = .001), and postoperative return to the operating room (OR, 4.75; 95% CI, 1.67-13.54; P = .004)., Conclusions: At U.S. hospitals, extrathoracic reconstruction is the more common reconstruction for supra-aortic trunk occlusive disease. Both approaches carry acceptably low rates of death, MI, and stroke. Transthoracic reconstruction results in more resource utilization because of its postoperative complications and greater complexity., (Copyright © 2014 Society for Vascular Surgery. All rights reserved.)

Background: Surgical patients and their physicians currently have tools to provide individualized prognostication for morbidity and mortality. For improved shared decision making, formal prediction of patient-centered outcomes is necessary. We derived and validated a simple, interview-based method to predict discharge home after surgery., Study Design: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Patient User File for 2011. Derivation in general and vascular surgery patients undergoing inpatient surgery was completed using serial multiple logistic regression. Validation was performed within multiple surgical specialties., Results: The derivation cohort included 88,068 patients, of whom 11,771 (13.4%) were not discharged home. The derived Home Calculator had excellent discrimination (c-statistic = 0.864) using 5 [corrected] variables: age, American Society of Anesthesiologists' performance status, elective surgery, and preadmission residence. Validation cohorts had varying rates of home discharge as follows: general (63,826 of 71,591, 89.2%), vascular (12,319 of 16,102, 76.5%), gynecologic (16,603 of 17,005, 97.6%), urologic (13,662 of 14,435, 94.6%), orthopaedic (12,000 of 19,514, 61.5%), thoracic (4,467 of 5,092, 87.7%). The Home Calculator provided good to excellent discrimination in validation cohorts: general (c = 0.866), vascular (c = 0.800), gynecologic (c = 0.793), urologic (c = 0.814), orthopaedic (c = 0.876), and thoracic (c = 0.800). Comparable discrimination was demonstrated in sensitivity analyses in surgical patients admitted exclusively from home., Conclusions: We derived and validated a simple Home Calculator that reliably predicts discharge to home after surgery and may be useful when counseling patients about postoperative course. Patient-centered tools such as this may allow physicians to better prepare patients and families for surgery and the recovery process., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Analysis of complex survey databases is an important tool for health services researchers. Missing data elements are challenging because the reasons for "missingness" are multifactorial, especially categorical variables such as race. We simulated missing data for race and analyzed the bias from five methods used in predicting major amputation in patients with critical limb ischemia (CLI)., Methods: Patient discharges with fully observed data containing lower extremity revascularization or major amputation and CLI were selected from the 2003 to 2007 Nationwide Inpatient Sample, a complex survey database (weighted n = 684,057). Considering several random missing data schemes, we compared five missing data methods: complete case analysis, replacement with observed frequencies, missing indicator variable, multiple imputation, and reweighted estimating equations. We created 100 simulated data sets, with 5%, 15%, or 30% of subjects' race drawn to be missing from the full data set. Bias was estimated by comparing the estimated regression coefficients averaged over 100 simulated data sets (β(miss)) from each method vs estimates from the fully observed data set (β(full)), with relative bias calculated as (β(full) - β(miss)/β(full)) × 100%., Results: Our results demonstrate that reweighted estimating equations produce the least biased and the missing indicator variable produces the most biased coefficients. Complete case analysis, replacement with observed frequencies, and multiple imputation resulted in moderate bias. Sensitivity analysis demonstrated the optimal method choice depends on the quantity and type of missing data encountered., Conclusions: Missing data are an important analytic topic in research with large databases. The commonly used missing indicator variable method introduces severe bias and should be used with caution. We present empiric evidence to guide method selection for handling missing data., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The share of total abdominal aortic aneurysm (AAA) repairs performed by endovascular aneurysm repair (EVAR) increased rapidly from 32% in 2001 to 65% in 2006 with considerable variation between states. We hypothesized that hospitals in competitive markets were early EVAR adopters and had improved AAA repair outcomes., Methods: Nationwide Inpatient Sample and linked Hospital Market Structure (HMS) data was queried for patients who underwent repair for nonruptured AAA in 2003. In HMS, the Herfindahl Hirschman Index (HHI, range 0-1) is a validated and widely accepted economic measure of competition. Hospital markets were defined using a variable geographic radius that encompassed 90% of discharged patients. We conducted bivariate and multivariable linear and logistic regression analyses for the dependent variable of EVAR use. A propensity score-adjusted multivariable logistic regression model was used to control for treatment bias in the assessment of competition on AAA repair outcomes., Results: A weighted total of 21,600 patients was included in our analyses. Patients at more competitive hospitals (lower HHI) were at increased odds of undergoing EVAR vs open repair (odds ratio, 1.127 per 0.1 decrease in HHI; P < .0127) after adjusting for patient demographics, comorbidities, and hospital level factors (bed size, teaching status, AAA repair volume, and ownership). Competition was not associated with differences in in-hospital mortality or vascular, neurologic, or other minor postoperative complications., Conclusions: Greater hospital competition is significantly associated with increased EVAR adoption at a time when diffusion of this technology passed its tipping point. Hospital competition does not influence post-AAA repair outcomes. These results suggest that adoption of novel vascular technology is not solely driven by clinical indications but may also be influenced by market forces., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Major amputation is often selected over infrainguinal bypass in patients with severe systemic comorbidities because it is assumed to have lower perioperative risks, yet this assumption is unproven and largely unexamined., Methods: The 2005 to 2008 National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients undergoing either infrainguinal bypass or major amputation using procedural codes. Patients with systemic or local infections were excluded. A subset of high-risk patients were then defined as American Society of Anesthesiologists (ASA) class 4 or 5, or ASA class 3 with renal failure, dyspnea at rest, ventilator dependence, recent congestive heart failure, or recent myocardial infarct. Propensity score matching was used to obtain two high-risk patient groups matched for preoperative characteristics., Results: No significant differences in demographic, preoperative, or anesthetic variables were found between the matched, high-risk amputation or bypass groups (792 and 780 patients, respectively). Bypass was associated with a lower 30-day postoperative mortality than amputation (6.54% vs 9.97%; P = .0147). Amputation was associated with higher rates of pulmonary embolism (0.9% vs 0% for amputation vs bypass groups, respectively; P = .009) and urinary tract infection (5.2% vs 2.7%; P = .01), while bypass was associated with higher rates of return to the operating room (14.1% vs 27.6%; P < .001) and a trend toward higher postoperative transfusion requirements (0.9% vs 2.1%; P = .054). The postoperative time to discharge did not differ between the two groups., Conclusion: The decision to perform an infrainguinal bypass or amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about different perioperative risks between the two procedures., (Copyright © 2011. Published by Mosby, Inc.)

Objective: Disparities in limb salvage procedures may be driven by socioeconomic status (SES) and access to high-volume hospitals. We sought to identify SES factors associated with major amputation in the setting of critical limb ischemia (CLI)., Methods: The 2003-2007 Nationwide Inpatient Sample was queried for discharges containing lower extremity revascularization (LER) or major amputation and chronic CLI (N = 958,120). The Elixhauser method was used to adjust for comorbidities. Significant predictors in bivariate logistic regression were entered into a multivariate logistic regression for the dependent variable of amputation vs LER., Results: Overall, 24.2% of CLI patients underwent amputation. Significant differences were seen between both groups in bivariate and multivariate analysis of SES factors, including race, income, and insurance status. Lower-income patients were more likely to be treated at low-LER-volume institutions (odds ratio [OR], 1.74; P < .001). Patients at higher-LER-volume centers (OR, 15.16; P <.001) admitted electively (OR, 2.19; P < .001) and evaluated with diagnostic imaging (OR, 10.63; P < .001) were more likely to receive LER., Conclusions: After controlling for comorbidities, minority patients, those with lower SES, and patients with Medicaid were more likely receive amputation for CLI in low-volume hospitals. Addressing SES and hospital factors may reduce amputation rates for CLI., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Conventional economic principles suggest that increases in competition are associated with price decreases. The purpose of this study is to determine whether this association holds true between objective measures of hospital competition and gross charges, by analyzing standardized operations where variations in costs should be minimal., Study Design: Hospital Market Structure file (from Agency for Healthcare Research and Quality, available for years 2000 and 2003) was linked to Nationwide Inpatient Sample database. Appendectomy, carotid endarterectomy, bariatric surgery, radical prostatectomy, and pyloromyotomy were analyzed, after excluding patients with possible complications. Primary outcomes included total hospital charges. Primary independent variable was Herfindahl-Hirschman Index (HHI) calculated by the Agency for Healthcare Research and Quality for each hospital based on its patient-flow market. Higher HHI represents the presence of more dominant hospitals in the market or lower competition., Results: A total of 162,823 patients from 1,492 hospitals (85,791 appendectomies, 38,619 carotid endarterectomies, 18,383 bariatric operations, 16,784 radical prostatectomies, 3,246 pyloromyotomies) were analyzed. Single linear regression analyses demonstrated higher HHI was significantly associated with lower hospital gross charges in all cases. On multivariate analysis, a 1 percentage-point increase on HHI was associated with -$114 for appendectomy, -$163 for carotid endarterectomy, and -$193 for radical prostatectomy (all p ≤ 0.001), and were independent of hospital urbanicity, teaching status, and payer mix. In contrast, no association was found between competition and hospital costs., Conclusions: Higher level of hospital competition is associated with higher hospital gross charges, although competition intensity is not associated with hospital costs. These data are important as health policy makers consider possible cost-control measures., (Copyright © 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Gender and ethnicity are factors affecting the incidence and severity of vascular disease as well as subsequent treatment outcomes. Although well studied in other fields, balanced enrollment of patients with relevant demographic characteristics in vascular surgery randomized controlled trials (RCTs) is not well known. This study describes the reporting of gender and ethnicity data in vascular surgery RCTs and analyzes whether these studies adequately represent our diverse patient population., Methods: We conducted a retrospective review of United States-based RCTs from 1983 through 2007 for three broadly defined vascular procedures: aortic aneurysm repair (AAR), carotid revascularization (CR), and lower extremity revascularization (LER). Included studies were examined for gender and ethnicity data, study parameters, funding source, and geographic region. The Nationwide Inpatient Sample (NIS) database was analyzed to obtain group-specific procedure frequency as an estimate of procedure frequency in the general population., Results: We reviewed 77 studies, and 52 met our inclusion criteria. Only 85% reported gender, and 21% reported ethnicity. Reporting of ethnicity was strongly associated with larger (>280 participants), multicenter, government-funded trials (P < .001 for all). Women are disproportionately under-represented in RCTs for all procedure categories (AAR, 9.0% vs 21.5%; CR, 30.0% vs 42.9%; LER, 22.4% vs 41.3%). Minorities are under-represented in AAR studies (6.0% vs 10.7%) and CR studies (6.9% vs 9.5%) but are over-represented in LER studies (26.0% vs 21.8%, P < .001 for all)., Conclusions: Minority ethnicity and female gender are under-reported and under-represented in vascular surgery RCTs, particularly in small, non-government-funded and single-center trials. The generalizability of some trial results may not be applicable to these populations. Greater effort to enroll a balanced study population in RCTs may yield more broadly applicable results.

Peripheral arterial disease (PAD) is a growing health problem for many Americans and often occurs along with other cardiovascular risk factors, including diabetes mellitus (DM), low-grade inflammation, hypertension, and lipid disorders. Intermittent claudication (IC), an early manifestation of PAD, commonly leads to reduced quality of life for patients who are limited in their ambulation. While recent wide adoption of percutaneous peripheral interventional (PPI) techniques has increased the number patients being aggressively treated for IC, the overall effectiveness of PPI for the treatment of IC is not well known, especially for DM patients who have both hemodynamic and functional obstacles to treatment success. This review is designed to illustrate how treatment outcomes for IC can be measured by different modalities and how diabetes and inflammation can influence those outcomes. In the setting of greater concern for health care resources and clinical accountability, better understanding of treatment outcomes and efficacy will help us manage these complex challenges.