542 results on '"Regenbogen, Scott E."'
Search Results
152. Sigmoid Diverticulitis
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Morris, Arden M., primary, Regenbogen, Scott E., additional, Hardiman, Karin M., additional, and Hendren, Samantha, additional
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- 2014
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153. The influence of employer-based health insurance and job support on receipt of adjuvant chemotherapy in stage III colorectal cancer.
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Veenstra, Christine Marie, primary, Regenbogen, Scott E., additional, Hawley, Sarah T., additional, Banerjee, Mousumi, additional, Kato, Ikuko, additional, Ward, Kevin C., additional, and Morris, Arden M., additional
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- 2013
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154. Patients, Priorities, and Decision Making in T1 Rectal Cancer
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Regenbogen, Scott E., primary
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- 2013
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155. Validation of the surgical Apgar score in a neurosurgical patient population
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Ziewacz, John E., primary, Davis, Matthew C., additional, Lau, Darryl, additional, El-Sayed, Abdulrahman M., additional, Regenbogen, Scott E., additional, Sullivan, Stephen E., additional, and Mashour, George A., additional
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- 2013
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156. Bias Correction for the Proportional Odds Logistic Regression Model with Application to a Study of Surgical Complications
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Lipsitz, Stuart R., primary, Fitzmaurice, Garrett M., additional, Regenbogen, Scott E., additional, Sinha, Debajyoti, additional, Ibrahim, Joseph G., additional, and Gawande, Atul A., additional
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- 2012
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157. Choosing Your First Job as a Surgeon and Health Services Researcher.
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Regenbogen, Scott E.
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- 2014
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158. A Policy-Based Intervention for the Reduction of Communication Breakdowns in Inpatient Surgical Care: Results From a Harvard Surgical Safety Collaborative
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Arriaga, Alexander F., primary, Elbardissi, Andrew W., additional, Regenbogen, Scott E., additional, Greenberg, Caprice C., additional, Berry, William R., additional, Lipsitz, Stuart, additional, Moorman, Donald, additional, Kasser, James, additional, Warshaw, Andrew L., additional, Zinner, Michael J., additional, and Gawande, Atul A., additional
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- 2011
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159. Critical Need for Objective Assessment of Postsurgical Patients
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Gawande, Atul A., primary and Regenbogen, Scott E., additional
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- 2011
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160. A Policy-based Intervention for the Reduction of Communication Breakdowns in Inpatient Surgical Care
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Arriaga, Alexander F., primary, Elbardissi, Andrew W., additional, Regenbogen, Scott E., additional, Greenberg, Caprice C., additional, Berry, William R., additional, Lipsitz, Stuart, additional, Moorman, Donald, additional, Kasser, James, additional, Warshaw, Andrew L., additional, Zinner, Michael J., additional, and Gawande, Atul A., additional
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- 2011
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161. Communication Practices on 4 Harvard Surgical Services
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ElBardissi, Andrew W., primary, Regenbogen, Scott E., additional, Greenberg, Caprice C., additional, Berry, William, additional, Arriaga, Alex, additional, Moorman, Donald, additional, Retik, Alan, additional, Warshaw, Andrew L., additional, Zinner, Michael J., additional, and Gawande, Atul A., additional
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- 2009
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162. The Better Colectomy Project
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Arriaga, Alexander F., primary, Lancaster, Robert T., additional, Berry, William R., additional, Regenbogen, Scott E., additional, Lipsitz, Stuart R., additional, Kaafarani, Haytham M. A., additional, Elbardissi, Andrew W., additional, Desai, Priya, additional, Ferzoco, Stephen J., additional, Bleday, Ronald, additional, Breen, Elizabeth, additional, Kastrinakis, William V., additional, Rubin, Marc S., additional, and Gawande, Atul A., additional
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- 2009
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163. Do Differences in Hospital and Surgeon Quality Explain Racial Disparities in Lower-Extremity Vascular Amputations?
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Regenbogen, Scott E., primary, Gawande, Atul A., additional, Lipsitz, Stuart R., additional, Greenberg, Caprice C., additional, and Jha, Ashish K., additional
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- 2009
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164. Novel strategies to prevent retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness
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Regenbogen, Scott E., primary, Greenberg, Caprice C., additional, Resch, Stephen C., additional, Kollengode, Anantha, additional, Cima, Robert R., additional, Zinner, Michael J., additional, and Gawande, Atul A., additional
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- 2008
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165. The Frequency and Significance of Discrepancies in the Surgical Count
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Greenberg, Caprice C., primary, Regenbogen, Scott E., additional, Lipsitz, Stuart R., additional, Diaz-Flores, Rafael, additional, and Gawande, Atul A., additional
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- 2008
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166. Does the Surgical Apgar Score Measure Intraoperative Performance?
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Regenbogen, Scott E., primary, Lancaster, R Todd, additional, Lipsitz, Stuart R., additional, Greenberg, Caprice C., additional, Hutter, Matthew M., additional, and Gawande, Atul A., additional
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- 2008
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167. Bar-coding Surgical Sponges To Improve Safety
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Greenberg, Caprice C., primary, Diaz-Flores, Rafael, additional, Lipsitz, Stuart R., additional, Regenbogen, Scott E., additional, Mulholland, Lynn, additional, Mearn, Francine, additional, Rao, Shilpa, additional, Toidze, Tamara, additional, and Gawande, Atul A., additional
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- 2008
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168. Post-Anesthetic Recovery Score
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Gawande, Atul A., primary, Regenbogen, Scott E., additional, Kwaan, Mary R., additional, and Zinner, Michael J., additional
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- 2007
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169. Patterns of Technical Error Among Surgical Malpractice Claims
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Regenbogen, Scott E., primary, Greenberg, Caprice C., additional, Studdert, David M., additional, Lipsitz, Stuart R., additional, Zinner, Michael J., additional, and Gawande, Atul A., additional
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- 2007
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170. Does performance matter? Role of intraoperative factors versus preoperative risk in surgical outcomes
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Regenbogen, Scott E., primary, Lancaster, R. Todd, additional, Lipsitz, Stuart R., additional, Greenberg, Caprice C., additional, Hutter, Matthew M., additional, and Gawande, Atul A., additional
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- 2007
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171. Private payer value initiatives: The Michigan Model
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Shubeck, Sarah P. and Regenbogen, Scott E.
- Abstract
The recent national emphasis on improving value in healthcare delivery has placed increasing responsibility for health care value improvement on individual hospitals through financial incentives. Private Payer Initiatives are partnerships between providers and hospitals with payers that are intended to improve quality and value of health care. Blue Cross Blue Shield of Michigan has been a pioneer in the development and financial support of “The Michigan Model.” The Michigan Model is a is a longstanding multifaceted initiative that has successfully improved quality of healthcare delivery throughout the state through the development of collaborations between providers and acute care hospitals.
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- 2018
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172. How to Be An Educated Consumer of Observational Data.
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Regenbogen, Scott E.
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- 2020
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173. Using Bayesian p-values in a 2 × 2 table of matched pairs with incompletely classified data.
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Yan Lin, Lipsitz, Stuart, Sinha, Debajyoti, Gawande, Atul A., Regenbogen, Scott E., and Greenberg, Caprice C.
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CONTINGENCY tables ,BAYESIAN analysis ,RANDOM variables ,COMMUNICATION ,MEDICAL sciences ,STATISTICS - Abstract
Altham proposed Bayesian p-values for the analysis of a 2×2 contingency table that is formed from matched pairs. Using the same Bayesian perspective, we develop an extension of Altham's Bayesian p-values to a 2×2 table from matched pairs with missing data that are missing at random. The approach is applied to a rater agreement study, in which two surgeon–reviewers rated whether or not there was a communication breakdown in malpractice cases. We also use a simulation study to explore the power and type I error rate of the Bayesian p-values. [ABSTRACT FROM AUTHOR]
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- 2009
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174. Association of Surgical Approaches and Outcomes in Total Mesorectal Excision and Margin Status for Rectal Cancer.
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Mirza, Muhammad Bilal, Gamboa, Adriana C., Irlmeier, Rebecca, Hopkins, Benjamin, Regenbogen, Scott E., Hrebinko, Katherine A., Holder-Murray, Jennifer, Wiseman, Jason T., Ejaz, Aslam, Wise, Paul E., Ye, Fei, Idrees, Kamran, Hawkins, Alexander T., Balch, Glen C., and Khan, Aimal
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RECTAL surgery , *RECTAL cancer , *SURGICAL margin , *SURGICAL blood loss , *ABDOMINOPERINEAL resection , *OPERATIVE surgery - Abstract
Despite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer. Patients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest. Among the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1). In patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques. • Optimal surgical approach for total mesorectal excision (TME) in rectal cancer remains unidentified. • Study reveals no significant differences in histopathological TME completeness, long-term outcomes (overall survival and recurrence-free survival), and overall TME quality between robotic and laparoscopic approaches in rectal cancer patients. • Higher margin positivity rates linked to robotic and open TME, potentially attributed to low rectal cancer cases in retrospective cohort. • Laparoscopic TME demonstrates lower intraoperative blood loss when compared to open surgical approach, robotic approach associated with fewer postoperative complications. • Robotic TME emerges as a safe and effective treatment option in rectal cancer surgery. • Large multicenter dataset analysis supports robust evidence-based practice in rectal cancer surgery. [ABSTRACT FROM AUTHOR]
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- 2024
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175. Surgical outcome measurement for a global patient population: Validation of the Surgical Apgar Score in eight countries
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Haynes, Alex B., Regenbogen, Scott E., Weiser, Thomas G., Lipsitz, Stuart R., Berry, William R., and Gawande, Atul A.
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- 2009
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176. Determinants of Value in Coronary Artery Bypass Grafting.
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Brescia, Alexander A., Vu, Joceline V., He, Chang, Li, Jun, Harrington, Steven D., Thompson, Michael P., Norton, Edward C., Regenbogen, Scott E., Syrjamaki, John D., Prager, Richard L., Likosky, Donald S., and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC) and the Michigan Value Collaborative (MVC)
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ECONOMIC impact ,MEDICARE ,HEALTH insurance & economics ,LENGTH of stay in hospitals ,FEE for service (Medical fees) ,RESEARCH ,CORONARY artery bypass ,KEY performance indicators (Management) ,TIME ,RESEARCH methodology ,MEDICAL care costs ,HOSPITAL costs ,SURGICAL complications ,PATIENT readmissions ,RETROSPECTIVE studies ,ACQUISITION of data ,MEDICAL cooperation ,EVALUATION research ,TREATMENT effectiveness ,COMPARATIVE studies ,CLINICAL medicine ,COST effectiveness ,QUALITY assurance ,ECONOMICS - Abstract
Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services. [ABSTRACT FROM AUTHOR]
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- 2020
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177. Reply
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Gawande, Atul A., Regenbogen, Scott E., Kwaan, Mary R., and Zinner, Michael J.
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- 2007
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178. Abstract 14159: Variation in Post-Acute Care Use and Spending After Cardiac Surgery.
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Thompson, Michael P, Dasmunshi, Sudipta, Syrjamaki, John D, Regenbogen, Scott E, Dupree, James M, Pagani, Francis D, and Likosky, Donald S
- Published
- 2018
179. Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium.
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Hrebinko, Katherine, Anto, Vincent P., Reitz, Katherine M., Gamboa, Adriana C., Regenbogen, Scott E., Hawkins, Alexander T., Hopkins, M. Benjamin, Ejaz, Aslam, Bauer, Philip S., Wise, Paul E., Balch, Glen C., and Holder-Murray, Jennifer
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RECTAL cancer , *ONCOLOGIC surgery , *URINARY diversion , *SURGICAL stomas , *TREATMENT effectiveness , *OSTOMY , *WEIGHT loss - Abstract
Purpose: Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. Methods: This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. Results: Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19–2.14]; p = 0.002), but significance was not met in multivariate models. Conclusion: Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study. [ABSTRACT FROM AUTHOR]
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- 2024
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180. Variation in utilization of palliative surgery in patients with metastatic colorectal cancer.
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Nathan, Hari, Regenbogen, Scott E, Hendren, Samantha, Morris, Arden M, and Suwanabol, Pasithorn Amy
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- 2016
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181. Hospital Performance in a Statewide Commercial Insurer Episode-Based Incentive Program.
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Thompson, Michael P., Cain-Nielsen, Anne H., Yost Karslake, Monica L., Pizzo, Chelsea A., Yaser, Jessica M., Syrjamaki, John D., Nathan, Hari, Norton, Edward C., and Regenbogen, Scott E.
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INSURANCE companies , *HOSPITALS , *EVALUATION of medical care , *MANAGED care programs , *EVALUATION of human services programs , *ELECTRONIC data interchange , *RETROSPECTIVE studies , *COST control , *PATIENT readmissions , *MEDICAL care use , *LABOR incentives , *DESCRIPTIVE statistics , *RESEARCH funding , *PAY for performance , *HOSPITAL charges , *LONGITUDINAL method - Abstract
OBJECTIVES: To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. STUDY DESIGN: Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry. METHODS: Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-indifferences (DID) analysis compared changes in patient-level episode spending associated with program implementation. RESULTS: Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation. CONCLUSIONS: There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics. [ABSTRACT FROM AUTHOR]
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- 2023
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182. Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection.
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Morgan, Daniel M., Kamdar, Neil, Regenbogen, Scott E., Krapohl, Greta, Swenson, Carolyn, Pearlman, Mark, Jr.Campbell, Darrel A., Hendren, Samantha, and Campbell, Darrel A Jr
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SURGICAL complications , *HOSPITAL administration , *HYSTERECTOMY , *SURGICAL site , *OPERATING rooms - Abstract
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. [ABSTRACT FROM AUTHOR]- Published
- 2018
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183. Complications after discharge predict readmission after colorectal surgery.
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Albright, Jeremy, Batool, Farwa, Cleary, Robert K., Mullard, Andrew J., Kreske, Edward, Ferraro, Jane, and Regenbogen, Scott E.
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COLON cancer , *PROCTOLOGY , *SURGICAL complications , *LAPAROSCOPIC surgery , *META-analysis - Abstract
Background: Health care providers, hospitals, and pay-for-performance programs are focused on strategies identifying patients at highest risk for re-admission after colorectal surgery. The study objective was to determine characteristics most associated with re-admission after elective colorectal surgery using a conceptual framework approach.Methods: This is an observational study of Michigan Surgical Quality Collaborative clinical registry data for 8962 colorectal surgery cases between July-2012 and April-2015. Separate mixed models were fit using known re-admission risk factors aligned in categories that may impact re-admissions by different mechanisms. Overall model discrimination was evaluated using Area Under the Curve estimated on a hold-out data set and examining differences in predicted versus observed re-admission across risk quintiles.Results: The overall 30-day re-admission rate was 10.5%. From Model 1 to Model 6, discrimination of re-admission was poor until Model 6 (AUC, 0.56, 0.61, 0.65, 0.63, 0.72, 0.81). Differences for observed re-admission rates comparing 'very low' versus 'very high' risk strata from Model 1 to Model 6 were 6%, 11%, 15%, 14%, 20%, and 30% respectively, and all comparisons were significant (p < 0.01). Though there were significant predictors in the first five models, most were no longer significant when additional predictors were included in subsequent models. Complications identified after discharge significantly increased the likelihood of re-admission and were the strongest predictors.Conclusion: Statistical models that include complications identified after discharge predict re-admission. Strategies to reduce re-admission after colorectal surgery should emphasize prevention of complications and more effective interventions to manage and ameliorate evolving complications identified after discharge. [ABSTRACT FROM AUTHOR]- Published
- 2019
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184. Comparison of lumen-apposing metal stents versus endoscopic balloon dilation for the management of benign colorectal anastomotic strictures.
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Kankotia RJ, Kwon RS, Philips GM, Regenbogen SE, Zacur GM, Wamsteker EJ, Schulman AR, and Machicado JD
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- Humans, Female, Male, Middle Aged, Retrospective Studies, Constriction, Pathologic surgery, Constriction, Pathologic therapy, Aged, Rectum surgery, Colon surgery, Treatment Outcome, Postoperative Complications therapy, Adult, Recurrence, Anastomosis, Surgical adverse effects, Dilatation methods, Stents, Colonoscopy methods
- Abstract
Background and Aims: Limited data exist evaluating lumen-apposing metal stents (LAMSs) with endoscopic balloon dilation (EBD) for the treatment of benign colorectal anastomotic strictures (BCASs). This study compares outcomes of both interventions., Methods: Patients with left-sided BCAS treated with LAMSs versus EBD were identified retrospectively. The primary outcome was a composite of crossover to another intervention to achieve clinical success or recurrence requiring reintervention., Results: Twenty-nine patients (11 LAMS and 18 EBD) were identified with longer follow-up in the EBD group (734 vs 142 days; P = .003). No significant differences were found in the composite outcome, technical success, clinical success, or components of composite outcome. With LAMS, there was a nonsignificant trend toward fewer procedures (2.4 vs 3.3; P = .06) and adverse events (0% vs 16.7%; P = .26)., Conclusions: LAMS appears to be as effective as EBD for the treatment of BCAS but may require fewer procedures and may be safer than EBD., Competing Interests: Disclosure The following author disclosed financial relationships: A. R. Schulman: Consultant for Apollo Endosurgery, Boston Scientific, Olympus, and MicroTech and research/grant support for GI Dynamics and Fractyl. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)
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- 2024
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185. Comparison of outcomes of abdominoperineal resection vs low anterior resection in very-low rectal cancer.
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Muldoon RL, Bethurum AJ, Gamboa AC, Zhang K, Ye F, Regenbogen SE, Abdel-Misih S, Ejaz A, Wise PE, Silviera M, Holder-Murray J, Balch GC, and Hawkins AT
- Abstract
Background: The management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal resection (APR) over low anterior resection (LAR) to optimize oncologic outcomes. This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer., Methods: The United States Rectal Cancer Consortium (2010-2016) was queried for adults who underwent either APR or LAR for stage I-III rectal cancers < 5 cm from anorectal junction and met inclusion criteria. The primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors., Results: A total of 431 patients with very-low rectal cancer who underwent APR or LAR were identified; 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. The median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-hazard ratio [HR] = 0.90, 95% CI: 0.53-1.52, P = .70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR = 1.29, 95% CI: 0.71-2.32, P = .39), complications (OR = 1.53, 95% CI: 0.94-2.50, P = .12), or length of stay (estimate: 0.04, SE = 0.25, P = .54)., Conclusion: We observed no significant difference in disease-free survival or overall survival between patients undergoing APR or LAR for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either APR or LAR., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)
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- 2024
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186. Hospital strategies in commercial episode-based reimbursement.
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Regenbogen SE, Cocroft S, Krein SL, and Thompson MP
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- Humans, Economics, Hospital, Quality Improvement, Qualitative Research, United States, Interviews as Topic, Episode of Care, Reimbursement, Incentive
- Abstract
Objectives: To understand hospitals' approaches to spending reduction in commercial episode-based payment programs and inform incentive design., Study Design: Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state's largest commercial payer., Methods: We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference-based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains., Results: Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment., Conclusions: The findings highlighted hospitals' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.
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- 2024
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187. Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer.
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Ali D, Syed M, Gamboa AC, Hawkins AT, Regenbogen SE, Holder-Murray J, Silviera M, Ejaz A, Balch GC, and Khan A
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- Adult, Humans, Retrospective Studies, Anastomosis, Surgical adverse effects, Surgical Flaps surgery, Anastomotic Leak etiology, Anastomotic Leak surgery, Rectal Neoplasms surgery, Rectal Neoplasms pathology
- Abstract
Background and Objectives: Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database., Methods: Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association., Results: A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [β = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]., Conclusions: Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak., (© 2023 Wiley Periodicals LLC.)
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- 2024
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188. What's the Matter With Trials Today?
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Regenbogen SE
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- 2024
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189. Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review.
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Hider AM, Gomez-Rexrode AE, Agius J, MacEachern MP, Ibrahim AM, Regenbogen SE, and Berlin NL
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- Humans, United States, Delivery of Health Care, Hospitals, Episode of Care, Medicare, Reimbursement Mechanisms, Patient Care Bundles
- Abstract
Objectives: To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions., Background Summary: Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear., Methods: A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion., Results: Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited., Conclusions: Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited., Competing Interests: Declaration of competing interest The authors have no financial or conflict of interests to disclose related to this work., (Copyright © 2023 Elsevier Inc. All rights reserved.)
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- 2024
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190. Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study.
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Janda AM, Vaughn MT, Colquhoun DA, Mentz G, Buehler K, Nathan H, Regenbogen SE, Syrjamaki J, Kheterpal S, and Shah N
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Background: The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry., Methods: In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods., Results: We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results., Conclusions: Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)
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- 2023
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191. Polygenic Risk Prediction in Diverticulitis.
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De Roo AC, Chen Y, Du X, Handelman S, Byrnes M, Regenbogen SE, Speliotes EK, and Maguire LH
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- Humans, Risk Factors, Michigan epidemiology, Genome-Wide Association Study, Genetic Predisposition to Disease, Diverticulitis
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Objective: To derive and validate a polygenic risk score (PRS) to predict the occurrence and severity of diverticulitis and to understand the potential for incorporation of a PRS in current decision-making., Background: PRS quantifies genetic variation into a continuous measure of risk. There is a need for improved risk stratification to guide surgical decision-making that could be fulfilled by PRS. It is unknown how surgeons might integrate PRS in decision-making., Methods: We derived a PRS with 44 single-nucleotide polymorphisms associated with diverticular disease in the UK Biobank and validated this score in the Michigan Genomics Initiative (MGI). We performed a discrete choice experiment of practicing colorectal surgeons. Surgeons rated the influence of clinical factors and a hypothetical polygenic risk prediction tool., Results: Among 2812 MGI participants with diverticular disease, 1964 were asymptomatic, 574 had mild disease, and 274 had severe disease. PRS was associated with occurrence and severity. Patients in the highest PRS decile were more likely to have diverticulitis [odds ratio (OR)=1.84; 95% confidence interval (CI), 1.42-2.38)] and more likely to have severe diverticulitis (OR=1.61; 95% CI, 1.04-2.51) than the bottom 50%. Among 213 surveyed surgeons, extreme disease-specific factors had the largest utility (3 episodes in the last year, +74.4; percutaneous drain, + 69.4). Factors with strongest influence against surgery included 1 lifetime episode (-63.3), outpatient management (-54.9), and patient preference (-39.6). PRS was predicted to have high utility (+71)., Conclusions: A PRS derived from a large national biobank was externally validated, and found to be associated with the incidence and severity of diverticulitis. Surgeons have clear guidance at clinical extremes, but demonstrate equipoise in intermediate scenarios. Surgeons are receptive to PRS, which may be most useful in marginal clinical situations. Given the current lack of accurate prognostication in recurrent diverticulitis, PRS may provide a novel approach for improving patient counseling and decision-making., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2023
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192. The Specific Aims Page: A Primer.
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Roberson JL, Maguire LH, Mitchem JB, Regenbogen SE, Smith JJ, and Huang E
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- 2023
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193. Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons.
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Aiken TJ, King R, Russell MM, Regenbogen SE, Lawson E, and Zafar SN
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- Humans, United States, Anticoagulants therapeutic use, Surveys and Questionnaires, Colon surgery, Postoperative Complications prevention & control, Venous Thromboembolism etiology, Venous Thromboembolism prevention & control, Venous Thromboembolism drug therapy, Colorectal Surgery adverse effects, Surgeons
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Background: Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations., Methods: An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines., Results: The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues., Conclusion: Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)
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- 2023
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194. High Complication Rate After Early Ileostomy Closure: Early Termination of the Short Versus Long Interval to Loop Ileostomy Reversal After Pouch Surgery Randomized Trial.
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Vogel JD, Fleshner PR, Holubar SD, Poylin VY, Regenbogen SE, Chapman BC, Messaris E, Mutch MG, and Hyman NH
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- Adult, Humans, Ileostomy adverse effects, Prospective Studies, Retrospective Studies, Postoperative Complications etiology, Colitis, Ulcerative surgery, Proctocolectomy, Restorative adverse effects
- Abstract
Background: In patients with ulcerative colitis who undergo IPAA, a diverting ileostomy is used to diminish the severity of anastomotic complications. Typically, the ileostomy is closed after an interval of 2 to 4 months. The safety of earlier closure of the ileostomy after pouch surgery is unknown., Objective: This study aimed to compare postoperative outcomes in patients randomly assigned to early (7-12 days) or late (≥8 weeks) ileostomy closure after ileal pouch construction., Design: This was a multicenter, prospective randomized trial., Setting: The study was conducted at colorectal surgical units at select United States hospitals., Patients: Adults with ulcerative colitis who underwent 2- or 3-stage proctocolectomy with IPAA were included., Main Outcome Measures: The primary outcomes included Comprehensive Complication Index at 30 days after ileostomy closure. The secondary outcomes included complications, severe complications, reoperations, and readmissions within 30 days of ileostomy closure., Results: The trial was stopped after interim analysis because of a high rate of complications after early ileostomy closure. Among 36 patients analyzed, 1 patient (3%) had unplanned proctectomy with end-ileostomy. Of the remaining 35 patients, 28 patients (80%) were clinically eligible for early closure and underwent radiologic assessment. There were 3 radiologic failures. Of the 25 remaining patients, 22 patients (88%) were randomly assigned to early closure (n = 10) or late closure (n = 12), and 3 patients were excluded. Median Comprehensive Complication Index was 14.8 (0-54) and 0 (0-23) after early and late closure (p = 0.02). One or more complications occurred in 7 patients (70%) after early closure and in 2 patients (17%) after late closure (p = 0.01)' and complications were severe in 3 patients (30%) after early closure and 0 patients after late closure (p = 0.04). Reoperation was required in 1 patient (10%) and 0 patients (p = 0.26) after early closure and readmission was required in 7 patients (70%) and 1 patient (8%) after late closure (p = 0.003)., Limitations: This study was limited by early study closure and selection bias., Conclusions: Early closure of a diverting ileostomy in patients with ulcerative colitis who underwent IPAA is associated with an unacceptably high rate of complications. See Video Abstract at http://links.lww.com/DCR/C68., Alta Tasa De Complicaciones Despus Del Cierre Precoz De La Ileostoma Terminacin Temprana Del Ensayo Aleatorizado De Intervalo Corto Versus Largo Para La Reversin De La Ileostoma En Asa Despus De La Ciruga De Reservorio Ileal: ANTECEDENTES:En los pacientes con colitis ulcerosa que se someten a una anastomosis del reservorio ileoanal, se utiliza una ileostomía de derivación para disminuir la gravedad de las complicaciones de la anastomosis. Por lo general, la ileostomía se cierra después de un intervalo de 2 a 4 meses. Se desconoce la seguridad del cierre más temprano de la ileostomía después de la cirugía de reservorio.OBJETIVO:Comparar los resultados posoperatorios en pacientes asignados al azar al cierre temprano (7-12 días) o tardío (≥ 8 semanas) de la ileostomía después de la construcción de un reservorio ileal.DISEÑO:Este fue un ensayo aleatorizado prospectivo multicéntrico.ESCENARIO:El estudio se realizó en unidades quirúrgicas colorrectales en hospitales seleccionados de los Estados Unidos.PACIENTES:Se incluyeron adultos con colitis ulcerosa que se sometieron a proctocolectomía en 2 o 3 tiempos con anastomosis ileoanal con reservorio.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron el Índice Integral de Complicaciones a los 30 días después del cierre de la ileostomía. Los resultados secundarios incluyeron complicaciones, complicaciones graves, reoperaciones y readmisiones dentro de los 30 días posteriores al cierre de la ileostomía.RESULTADOS:El ensayo se detuvo después del análisis interino debido a una alta tasa de complicaciones después del cierre temprano de la ileostomía. Entre los 36 pacientes analizados, 1 (3%) tuvo una proctectomía no planificada con ileostomía terminal. De los 35 pacientes restantes, 28 (80%) fueron clínicamente elegibles para el cierre temprano y se sometieron a una evaluación radiológica. Hubo 3 fracasos radiológicos. De los 25 pacientes restantes, 22 (88 %) se asignaron al azar a cierre temprano (n = 10) o tardío (n = 12) y 3 fueron excluidos. La mediana del Índice Integral de Complicaciones fue de 14,8 (0-54) y 0 (0-23) después del cierre temprano y tardío (p = 0,02). Una o más complicaciones ocurrieron en 7 pacientes (70%) después del cierre temprano y 2 (17%) pacientes después del cierre tardío (p = 0,01) y fueron graves en 3 (30%) y 0 pacientes, respectivamente (p = 0,04). Requirieron reintervención en 1 (10%) y 0 (p = 0,26) y reingreso en 7 (70%) y 1 (8%) pacientes (p = 0,003).LIMITACIONES:Este estudio estuvo limitado por el cierre temprano del estudio; sesgo de selección.CONCLUSIONES:El cierre temprano de una ileostomía de derivación en pacientes con colitis ulcerosa con anastomosis de reservorio ileoanal se asocia con una tasa inaceptablemente alta de complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/C68. (Traducción-Dr. Felipe Bellolio)., (Copyright © The ASCRS 2022.)
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- 2023
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195. Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis.
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Hawkins AT, Rothman R, Geiger TM, Bonnet KR, Mutch MG, Regenbogen SE, Schlundt DG, and Penson DF
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Objective: This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making., Summary Background Data: The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions., Methods: We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework., Results: 25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/]., Conclusions: Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development., Competing Interests: Conflicts of Interest: None
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- 2022
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196. What's the magic number? Impact of time to initiation of treatment for rectal cancer.
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Edwards GC, Gamboa AC, Feng MP, Muldoon RL, Hopkins MB, Abdel-Misih S, Balch GC, Holder-Murray J, Mohammed M, Regenbogen SE, Silviera ML, and Hawkins AT
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- Chemoradiotherapy, Chemotherapy, Adjuvant, Humans, Neoadjuvant Therapy, Neoplasm Staging, Retrospective Studies, Treatment Outcome, United States epidemiology, Neoplasm Recurrence, Local pathology, Rectal Neoplasms surgery
- Abstract
Background: National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis., Methods: This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality., Results: A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively., Conclusion: This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days., (Copyright © 2021 Elsevier Inc. All rights reserved.)
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- 2022
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197. Wide Variation in Surgical Spending Within Hospital Systems: A Missed Opportunity for Bundled Payment Success.
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Chhabra KR, Sheetz KH, Regenbogen SE, Dimick JB, and Nathan H
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- Aged, Cost Control, Cross-Sectional Studies, Female, Humans, Male, United States, Arthroplasty, Replacement, Hip statistics & numerical data, Hospital Costs statistics & numerical data, Medicare economics, Patient Care Bundles economics
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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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2021
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198. Readiness of Graduating General Surgery Residents to Perform Colorectal Procedures.
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Vu JV, George BC, Clark M, Rivard SJ, Regenbogen SE, and Kwakye G
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- Bayes Theorem, Clinical Competence, Cohort Studies, Education, Medical, Graduate, Humans, United States, Colorectal Neoplasms, General Surgery education, Internship and Residency
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Objective: In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency., Design: This was a retrospective observational cohort study. Attending ratings of residents' intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects., Setting: Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC)., Patients: We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations., Results: A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure., Conclusions: General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2021
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199. Impact of Postoperative Complications on Oncologic Outcomes After Rectal Cancer Surgery: An Analysis of the US Rectal Cancer Consortium.
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Gamboa AC, Lee RM, Turgeon MK, Varlamos C, Regenbogen SE, Hrebinko KA, Holder-Murray J, Wiseman JT, Ejaz A, Feng MP, Hawkins AT, Bauer P, Silviera M, Maithel SK, and Balch GC
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- Aged, Disease-Free Survival, Female, Gastrectomy, Humans, Male, Middle Aged, Neoadjuvant Therapy, Postoperative Complications etiology, Retrospective Studies, Survival Rate, Rectal Neoplasms surgery
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Background: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not well studied., Methods: The United States Rectal Cancer Consortium (2007-2017) was reviewed for primary rectal adenocarcinoma patients who underwent R0/R1 resection. Ninety-day POCs were categorized as major or minor and were grouped into infectious, cardiopulmonary, thromboembolic, renal, or intestinal dysmotility. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS)., Results: Among 1136 patients, the POC rate was 46% (n = 527), with 63% classified as minor and 32% classified as major. Of all POCs, infectious complications comprised 20%, cardiopulmonary 3%, thromboembolic 5%, renal 9%, and intestinal dysmotility 19%. Compared with minor or no POCs, major POCs were associated with both worse RFS and worse OS (both p < 0.01). Compared with no POCs, a single POC was associated with worse RFS (p < 0.01), while multiple POCs were associated with worse OS (p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (p < 0.01), while cardiopulmonary and thromboembolic POCs were associated with worse OS (both p < 0.01). Renal POCs were associated with both worse RFS (p < 0.001) and worse OS (p = 0.01). After accounting for pathologic stage, neoadjuvant therapy, and final margin status, Multivariable analysis (MVA) demonstrated worse outcomes with cardiopulmonary, thromboembolic, and renal POCs for OS (cardiopulmonary: hazard ratio [HR] 3.6, p = 0.01; thromboembolic: HR 19.4, p < 0.01; renal: HR 2.4, p = 0.01), and renal and infectious POCs for RFS (infectious: HR 2.1, p < 0.01; renal: HR 3.2, p < 0.01)., Conclusions: Major complications after proctectomy for cancer are associated with decreased RFS and OS. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.
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- 2021
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200. Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.
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Schuman AD, Syrjamaki JD, Norton EC, Hallstrom BR, and Regenbogen SE
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- Administrative Claims, Healthcare statistics & numerical data, Aged, Arthroplasty, Replacement, Hip economics, Arthroplasty, Replacement, Knee economics, Cost Savings standards, Cost Savings statistics & numerical data, Cost-Benefit Analysis statistics & numerical data, Female, Humans, Male, Medical Overuse economics, Medical Overuse statistics & numerical data, Medicare economics, Medicare standards, Medicare statistics & numerical data, Michigan, Patient Readmission economics, Patient Readmission statistics & numerical data, Patient Transfer economics, Patient Transfer standards, Patient Transfer statistics & numerical data, Retrospective Studies, Skilled Nursing Facilities economics, Subacute Care economics, Subacute Care standards, United States, Arthroplasty, Replacement, Hip rehabilitation, Arthroplasty, Replacement, Knee rehabilitation, Medical Overuse prevention & control, Skilled Nursing Facilities statistics & numerical data, Subacute Care statistics & numerical data
- Abstract
Background: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments., Methods: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests., Results: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use., Conclusion: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement., (Copyright © 2020 Elsevier Inc. All rights reserved.)
- Published
- 2021
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