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Context: Risk factors for perioperative mortality after coronary artery bypass graft (CABG) surgery have been extensively studied. However, which factors are associated with early readmissions following CABG surgery are less clear., Objective: To identify significant predictors of readmission within 30 days following CABG surgery., Design, Setting, and Patients: Causes for readmission within 30 days were investigated for all patients discharged after CABG surgery in the state of New York from January 1, 1999, through December 31, 1999. A variety of patient demographics, preoperative risk factors, complications, operative and postoperative factors, and provider characteristics were considered as potential predictors of readmissions., Main Outcome Measure: Hospital readmissions within 30 days of discharge following CABG surgery., Results: Of 16 325 total patients, 2111 (12.9%) were readmitted within 30 days for reasons related to CABG surgery. The most common causes of readmission were postsurgical infection (n = 598 [28%]) and heart failure (n = 331 [16%]). Eleven risk factors were found to be independently associated with higher readmission rates: older age, female sex, African American race, greater body surface area, previous myocardial infarction within 1 week, and 6 comorbidities. After controlling for these preoperative patient-level risk factors, 2 provider characteristics (annual surgeon CABG volume <100, hospital risk-adjusted mortality rate in the highest decile) and 2 postoperative factors (discharge to nursing home or rehabilitation/acute care facility, length of stay during index CABG admission of > or =5 days) were also related to higher readmission rates., Conclusions: Readmission within 30 days following discharge is an important adverse outcome of CABG surgery. Continued attempts should be made to explore the potential of readmission as a supplement to mortality in assessing provider quality.

Objectives: Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions., Research Design: Retrospective Cohort Study., Subjects: Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696)., Methods: Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P <0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD)., Results: Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P <0.001) with increasing volume (3.6% in low [<500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [>1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P <0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01)., Conclusions: VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.

Background: Hip fracture is associated with significant mortality and disability. Patients who are discharged from the hospital with active clinical problems may have worse outcomes than those patients without active clinical problems., Objective: To assess the frequency and impact of clinical problems at discharge on clinical and functional hip fracture outcomes., Methods: Detailed clinical data were collected from 559 patients in a prospective, multicenter observational cohort study. Active clinical issues (ACIs) on discharge included the following: temperature of 38.3 degrees C or higher, heart rate of more than 100/min or less than 60/min, systolic blood pressure higher than 180 mm Hg or lower than 90 mm Hg, diastolic blood pressure higher than 110 mm Hg or lower than 60 mm Hg, respiratory rate of more than 24/min, oxygen saturation of less than 90%, altered mental status, no oral intake, shortness of breath, chest pain, arrhythmias, or wound infection. New impairments (NIs) included bowel and bladder incontinence, inability to get out of bed, and decubitus ulcer. Outcomes were deaths, readmissions, and functional mobility 60 days after discharge., Results: Overall, 94 patients (16.8%) had 1 or more ACIs, and 229 (41.0%) had 1 or more NIs on discharge. Both ACIs and NIs on discharge were associated with increased risk-adjusted rates of death (odds ratio, 1.8; 95% confidence interval, 1.2-2.8) or readmission (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The NIs on discharge were also associated with worse functional mobility (P<.004). These relationships persisted in multivariate analyses that controlled for a previously validated, hip fracture-specific risk adjustment measure., Conclusions: Clinicians should consider information about ACIs and NIs when deciding readiness for discharge and planning post-acute care.

Context: Certificate of need regulation was designed to control health care costs by preventing health care facilities from expanding unnecessarily. While there have been several studies investigating whether these regulations have affected health care investment, few have evaluated the relationship between certificate of need regulation and quality of care., Objective: To compare risk-adjusted mortality and hospital volumes for coronary artery bypass graft (CABG) surgery in states with and without certificate of need regulation., Design, Setting, and Participants: Retrospective cohort study of 911 407 Medicare beneficiaries aged 65 years or older, who underwent CABG surgery between 1994 and 1999 in 1063 US hospitals., Main Outcome Measures: States (and the District of Columbia) with continuous (n = 27), none (n = 18), or intermittent (n = 6) certificate of need regulation; mortality (in-hospital or within 30 days of CABG surgery) rates; and mean annual hospital volumes for CABG surgery., Results: Unadjusted mortality was 5.1% in states without certificate of need regulation compared with 4.4% in states with continuous regulation, and 4.3% in states with intermittent certificate of need regulation (P<.001 for each comparison). Adjusting for demographic and clinical factors, mortality remained higher in states without certificate of need regulation compared with states with continuous certificate of need regulation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.15-1.28; P<.001). Using the same groups for comparison, the mean annual hospital volume for CABG surgery was 84% lower in states without certificate of need regulation (104 vs 191; P<.001) and more patients underwent CABG surgery in low-volume hospitals (<100 procedures annually) (30% vs 10% for states with continuous certificate of need programs; P<.001). Following the repeal of certificate of need regulation in states categorized as intermittent, the percentage of patients undergoing CABG surgery in low-volume hospitals tripled., Conclusions: Mortality rates for Medicare patients undergoing CABG surgery were higher in states without certificate of need regulation. Repeal of certificate of need regulations during the study period was associated with declines in hospital volume for CABG surgery.

Background: It is more convenient and less costly to perform percutaneous coronary interventions (PCIs) in the catheterization laboratory after catheterization, but there is some doubt as to whether it is harmful to patients. Other studies on this topic have been hampered by small sample sizes and an inability to separate patients who underwent PCI after catheterization in the same admission from patients who underwent PCI in a subsequent admission., Methods: Data from New York's PCI registry were used to develop a statistical model that predicted inhospital mortality based on preprocedural patient characteristics and the timing of the PCI (at same time as catheterization [combined procedure] or in the same admission as catheterization, but not at the same time [staged procedure]). The difference in mortality for the timing options was compared after adjusting for patient risk factors., Results: Patients undergoing combined catheterization and PCI were more likely to have undergone a previous PCI and less likely to have had chronic obstructive pulmonary disease, renal failure, a history of congestive heart failure, carotid disease, or diabetes than patients who underwent a staged procedure. After adjustment for patient risk, there were no significant differences in mortality for the 2 timing options (OR 1.14, P =.38 for combined vs staged procedures). However, patients who underwent combined procedures who had congestive heart failure in the same admission or who had Canadian Cardiovascular Society class IV had odds ratios significantly higher than congestive heart failure patients who underwent staged procedures (OR = 1.59, P =.04 and OR = 1.64, P =.04, respectively)., Conclusions: Combined procedures appear to have mortality as low as staged procedures on average, but are less effective for some groups of high-risk patients.

Objectives: To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture., Design: Prospective cohort study., Setting: Four hospitals in the New York City metropolitan area., Participants: Consecutive patients aged 50 and older admitted with diagnosis of hip fracture to these four hospitals between August 1997 and August 1998., Measurements: Time of injury, time of arrival to the emergency room, and time of surgery were recorded and used to calculate intervals between injury and hospital arrival and between hospital arrival and surgical repair., Results: Of the 571 patients enrolled, 99 (17%) arrived at the hospital more than 24 hours after injury. After hospital arrival, 17 (3%) patients did not have surgery, 166 (29%) had surgery within 24 hours of arrival, and 388 (68.0%) had surgery more than 24 hours after arrival (median 41 hours, range 25-584). For those patients who had surgery after 24 hours, 163 (29.4%) had surgery 25 to 36 hours after hospital arrival, 102 (18.4%) had surgery 37 to 48 hours after arrival, and 123 (22.2%) had surgery more than 48 hours after arrival. The primary reasons for delaying surgery more than 24 hours after hospital arrival were waiting for routine medical clearance (52%) and unavailability of the operating suite or surgeon (29%). Stabilization of associated medical conditions resulted in the lengthiest periods of delay., Conclusion: A wait time of more than 24 hours from hospitalization to surgical repair of hip fracture in older patients is common. Some of this delay time is patient related and some occurs because of systems factors and may be avoidable. The extent to which surgical timing affects survival and functional recovery needs more detailed examination.

Objectives: To present several alternative approaches to describing the range and functional outcomes of patients with hip fracture., Design: Prospective study with concurrent medical records data collection and patient and proxy interviews at the time of hospitalization and 6 months later., Setting: Four hospitals in the New York metropolitan area., Participants: Five hundred seventy-one hospitalized adults aged 50 and older with hip fracture between July 1997 and August 1998., Measurements: Rates of return to function in four physical domains, mortality, and nursing home residence at 6 months. Cluster analysis was used to describe the heterogeneity among the sample and identify variations in 6-month mortality, nursing home residence, and level of functioning and to develop a patient classification tree with associated patient outcomes at 6 months postfracture., Results: In locomotion, transfers, and self-care, 33% to 37% of patients returned to their prior level of function by 6 months, including those needing assistance, but only 24% were independent in locomotion at 6 months. Cluster analysis identified eight patient subgroups that had distinct baseline features and variable outcomes at 6 months. The patient classification tree used four variables: atypical functional status (independent in locomotion but dependent in other domains); nursing home residence; independence/dependence in self-care; and age younger than 85 or 85 and older that identified five subgroups with variable 6-month outcomes that clinicians may use to predict likely outcomes for their patients., Conclusion: Patients with hip fracture are heterogeneous with respect to baseline and outcome characteristics. Clinicians may be better able to give patients and caregivers information on expected outcomes based on presenting characteristics used in the classification tree.

Background: This study explores the volume-mortality relationship for 3 groups of cancer procedures to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated with lower in-hospital mortality., Methods: New York's Statewide Planning and Research Cooperative System was used to identify more than 32,000 hospital inpatients with a cancer diagnosis who underwent colectomy, lobectomy of the lung, or gastrectomy between January 1, 1994, and December 31, 1997. The association of in-hospital mortality rates with provider (hospital and surgeon) volume was examined after adjusting for differences in age, demographics, organ metastasis, socioeconomic status, and comorbidities., Results: For hospital volume for gastrectomy, the highest-volume quartile had an absolute risk-adjusted mortality rate that was 7.1% lower (P <.0001) than the lowest-volume quartile, although the overall mortality rate for the procedure was only 6.2%. For surgeon volume for colectomy, the highest- and lowest- volume quartiles differed by 1.9% (P <.0001), although the procedure mortality rate was only 3.5%. For hospital volume for lung lobectomy, the absolute difference in mortality was 1.7%. Patients undergoing operations performed by high-volume surgeons in high-volume hospitals usually had significantly lower risk-adjusted mortality rates than did patients who had low-volume surgeons or who were in low-volume hospitals, or both., Conclusions: For all 3 procedure groups, the risk-adjusted in-hospital mortality is significantly lower when the procedures are performed by high-volume providers.

Objective: Previous analyses of variability in bypass resource use have not focused on hospital-level variation or adequately explored the influence of patient risk. We combined a clinical database with claims data to fully characterize patient level and hospital level variability in bypass surgery cost and length of stay in New York State and explored the extent to which lower cost is associated with worse quality of care., Methods: By use of 1992 clinical and claims data, we identified by multivariable regression which patient characteristics influence bypass cost and length of stay. Hospital was then incorporated as a random variable in mixed linear models to determine its impact on resource use. The relationship between risk-adjusted in-hospital mortality and cost was then explored., Results: In the 21 hospitals for which cost data were available, mean leveled cost (exclusive of professional fees and noncomparable costs) was $15,713, with a mean length of stay of 14 days (n = 12,087). One fifth of the variation in resource use was explained by baseline patient risk. After adjustment for patient risk, hospital explained an additional 42% of variation in cost and an additional 8% of variation in length of stay. Among hospitals, risk-adjusted cost varied almost 3-fold and risk-adjusted length of stay varied 50%. There was no association between cost and in-hospital mortality., Conclusions: As of 1992, there was considerable interhospital variability in bypass surgery cost after patient baseline risk was accounted for. This suggests that reductions in bypass cost could be achieved by normalizing clinical practice.

Background and Purpose: Because there is considerable variation in practice patterns and outcomes for carotid endarterectomy (CE), there is a need to study the processes of care that are associated with adverse outcomes. The purpose of this study was to examine the impact of processes of care and surgical specialty on adverse outcomes for CE., Methods: A retrospective cohort study based on a voluntary CE registry containing 3644 patients undergoing CE between April 1, 1997, and March 31, 1999, in New York hospitals was used in the study. A multivariable statistical model was used to identify significant independent patient risk factors and to examine the association of processes of care and surgical specialty with outcomes after adjustment for differences in patient risk factors., Results: The overall adverse outcome (in-hospital death or stroke) rate was 1.84%. After adjustment for differences in 7 patient risk factors that were significantly related to adverse outcomes, the use of >/=1 specific processes of care (eversion endarterectomy, protamine, or shunts) was found to be associated with lower odds of an adverse outcome relative to patients undergoing CE without the processes (OR=0.42, P=0.006). Similarly, patients undergoing surgery performed by vascular surgeons had lower odds of experiencing an adverse outcome (OR=0.36, P=0.009). Processes of care and surgical specialty were highly correlated with one another., Conclusions: Processes of care and surgical specialty are significant interrelated determinants of adverse outcome for CE.

Background: Acute myocardial infarction, cardiac arrest, and other cardiac events are the major cause of mortality among patients with renal insufficiency. Previous studies of interventions for coronary artery disease among patients with renal insufficiency have not controlled for potentially confounding factors such as coronary artery disease severity and left ventricular function. This study investigates the comparative survival for patients with renal insufficiency and coronary artery disease following coronary artery bypass graft (CABG) surgery as compared with percutaneous coronary artery intervention (PCI), while controlling for confounding factors., Methods: This retrospective cohort study of patients undergoing CABG surgery or PCI discharged between 1993 and 1995 uses the New York Department of Health databases and Cox proportional hazards analyses to estimate the mortality risk associated with CABG as compared with PCI for patients with renal insufficiency. Renal function was categorized as creatinine <2.5 mg/dL (N = 58,329), creatinine > or =2.5 mg/dL (N = 840), and end-stage renal disease (ESRD) requiring dialysis (N = 407)., Results: Patients with either ESRD or serum creatinine > or =2.5 mg/dL had more severe coronary artery disease and a greater frequency of comorbid conditions as compared with patients with creatinine <2.5 mg/dL. Creatinine > or =2.5 mg/dL and ESRD were both associated with an increased mortality risk among all distributions of coronary artery disease anatomy. Among patients with ESRD, the risk ratio (RR) of mortality for patients undergoing CABG compared with PCI was 0.39 (95% CI, 0.22 to 0.67, P = 0.0006). Among patients with creatinine > or =2.5 mg/dL, CABG surgery did not convey a survival benefit over PCI (RR, 0.86, 95% CI, 0.56 to 1.33, P = 0.50)., Conclusions: This study demonstrates a survival benefit among patients with ESRD undergoing CABG surgery as compared with PCI, while controlling for severity of coronary artery disease, left ventricular dysfunction, and other comorbid conditions. These results suggest that management decisions among patients with coronary artery disease should be made in the context of not only location and severity of coronary artery lesions, but also on the presence and severity of renal dysfunction.

Objectives: The goal of this study was to learn more about the risk factors and short- and long-term outcomes for primary angioplasty., Background: Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has been an effective alternative to thrombolytic therapy for patients with acute myocardial infarction (AMI). However, most reported studies have been compromised by small sample sizes and short observation times., Methods: New York's coronary angioplasty registry was used to identify New York patients undergoing angioplasty within 6 h of AMI between January 1, 1993 and December 31, 1996. Statistical models were used to identify significant risk factors for in-patient and long-term survival and to estimate long-term survival for all patients as well as various subsets of patients undergoing primary angioplasty., Results: The in-hospital mortality rate for all primary angioplasty patients was 5.81%. When patients in preprocedural shock (who had a mortality rate of 45%) were excluded, the in-hospital mortality rate dropped to 2.60%. Mortality rates for all primary angioplasty patients at one year, two years and three years were 9.3%, 11.3% and 12.6%, respectively. Patients treated with stent placement did not have significantly lower risk-adjusted in-patient or two-year mortality rates., Conclusions: Primary angioplasty is a highly effective option for AMI.

Background: The objective of this study was to identify the mortality rates and significant independent risk factors for mortality for each of six valve replacement groups., Methods: A total of 14,190 patients who underwent valve replacement in New York State from 1995 to 1997 were classified into six major groups and significant independent risk factors for inpatient mortality were identified for each of the groups using stepwise logistic regression., Results: Mortality rates ranged from 3.33% for isolated aortic valve surgical procedures to 18.72% for multiple valve replacements with coronary artery bypass graft operations. The number of years in excess of age 55 was a significant multivariate predictor of mortality for all six groups of patients. Shock was a significant predictor for five of the six groups, and in each of those groups it was the risk factor with the highest odds ratio., Conclusions: Significant patient risk factors are relatively consistent across different types of valve replacement procedures. The probability of survival from valve surgical procedures is highly dependent on the patient's preoperative profile and the type of valve operation.

Objectives: We sought to compare patient outcomes for coronary stent placement and balloon angioplasty., Background: Since 1994, the number of patients treated only with balloon angioplasty has decreased nationally, whereas the use of coronary stents as an alternative has grown tremendously. The objectives of this study were to compare short- and long-term survival and subsequent revascularization rates for patients undergoing single-vessel balloon angioplasty and coronary stent placement., Methods: New York's Coronary Angioplasty Registry was used to identify New York patients undergoing either balloon angioplasty or stent placement between July 1, 1994, and December 31, 1996. Statistical models were used to compare risk-adjusted short- and long-term survival and subsequent coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCIs)., Results: No significant differences were found in adjusted in-patient mortality, but patients who had balloon angioplasty were, on average, 1.36 times more likely to have died at any time during the two-year period after the index procedure (p = 0.003). The adjusted in-patient CABG rate was significantly higher for balloon angioplasty (2.72% vs. 1.66%, p<0.0001), and the adjusted two-year CABG rate was also significantly higher for balloon angioplasty (10.81% vs. 7.25%, p<0.001). The adjusted two-year rate for subsequent PCIs was also significantly higher for balloon angioplasty (19.6% vs. 14.3%, p<0.0001). Although measures were taken to eliminate or minimize the effect of selection bias, it should be noted that patients with stents were healthier at hospital admission than patients who had balloon angioplasty., Conclusions: Stent placement is associated with significantly lower risk-adjusted long-term mortality, CABG and subsequent PCI rates, as compared with balloon angioplasty.

Context: Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown., Objective: To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals., Design: A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance., Setting: Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%)., Patients: A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care., Main Outcome Measure: Probability of a patient receiving CABG surgery at a lower-mortality hospital., Results: Compared with patients with private FFS insurance (n = 18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n = 31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004)., Conclusions: Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.

Purpose: The aim of this study was to identify significant independent predictors of inpatient mortality rates for pediatric victims of blunt trauma and to develop a formula for predicting the probability of inpatient mortality for these patients., Methods: Emergency department and inpatient data from 2,923 pediatric victims of blunt injury in the New York State Trauma Registry in 1994 and 1995 were used to explore the relationship between patient risk factors and mortality rate. A stepwise logistic regression model with P<.05 was developed using survival status asthe dependent variable. Independent variables included are elements of the Pediatric Trauma Score (PTS), additional elements from the Revised Trauma Score (RTS), the motor response and eye opening components of the Glasgow Coma Scale (GCS), age-specific systolic blood pressure, the AVPU score, and 2 measures of anatomic injury severity (the Injury Severity Score [ISS] and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS])., Results: The only significant independent predictors of severity that emerged were the ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component from the AVPU score. The statistical model exhibited an excellent fit (C statistic = .964). The specificity associated with the prediction of inpatient mortality rate based on the presence of 1 or more of these risk factors was .926, and the sensitivity was .944., Conclusion: The best independent predictors of inpatient mortality rate for pediatric trauma patients with blunt injuries include variables not specifically contained in the PTS or the RTS: ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component of the AVPU score.

Background: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach., Methods: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996., Results: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state., Conclusions: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.

Objectives: The purpose of this study was to compare 3-year risk-adjusted survival in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty., Background: Coronary artery bypass graft surgery and angioplasty are two common treatments for coronary artery disease. For referral purposes, it is important to know the relative pattern of survival after hospital discharge for these procedures and to identify patient characteristics that are related to survival., Methods: New York's CABG surgery and angioplasty registries were used to identify New York patients undergoing CABG surgery and angioplasty from January 1, 1993 to December 31, 1995. Mortality within 3 years of undergoing the procedure (adjusted for patient severity of illness) and subsequent revascularization within 3 years were captured. Three-year mortality rates were adjusted using proportional hazards methods to account for baseline differences in patients' severity of illness., Results: Patients with one-vessel disease with the one vessel not involving the left anterior descending artery (LAD) or with less than 70% LAD stenosis had a statistically significantly longer adjusted 3-year survival with angioplasty (95.3%) than with CABG surgery (92.4%). Patients with proximal LAD stenosis of at least 70% had a statistically significantly longer adjusted 3-year survival with CABG surgery than with angioplasty regardless of the number of coronary vessels diseased. Also, patients with three-vessel disease had a statistically significantly longer adjusted 3-year survival with CABG surgery regardless of proximal LAD disease. Patients with other one-vessel or two-vessel disease had no treatment-related differences in survival., Conclusions: Treatment-related survival benefit at 3-years in patients with ischemic heart disease is predicted by the anatomic extent and specific site of the disease, as well as by the treatment chosen.

Background and Purpose: The objective of this study was to assess the relationship between each of 2 provider volume measures for carotid endarterectomies (CEs) (annual hospital volume and annual surgeon volume) and in-hospital mortality. New York's Statewide Planning and Research (SPARCS) administrative database was used to identify all 28 207 patients for whom carotid endarterectomy was the principal procedure performed in New York State hospitals between January 1, 1990, and December 31, 1995., Methods: A statistical model was developed to predict in-hospital mortality using age, admission status, and several conditions found to be associated with higher-than-average mortality. This model was then used to calculate risk-adjusted mortality rates for various intersections of hospital and surgeon volume ranges., Results: Risk-adjusted in-hospital mortality ranged from 1.96% (95% confidence interval, 1.47 to 2.57) for patients having surgeons with annual CE volumes of <5 in hospitals with annual CE volumes of /=5 in hospitals with annual CE volumes of >100. These 2 rates were statistically different., Conclusions: We conclude that the in-hospital mortality rates for carotid endarterectomies performed by surgeons with extremely low annual volumes (<5) and for hospitals with low volumes (

Objective: To examine the relationship between annual provider (hospital and surgeon) volume of pediatric cardiac surgery and in-hospital mortality., Design: Population-based retrospective cohort study using a clinical database., Setting: The 16 acute care hospitals in New York with certificate of need approval to perform pediatric cardiac surgery., Patients: All children undergoing congenital heart surgery in New York from 1992 to 1995., Main Outcome Measures: Risk-adjusted mortality rates for various hospital and surgeon volume ranges. Adjustments were made for severity of illness using logistic regression., Results: A total of 7169 cases were analyzed. After controlling for severity of preprocedural illness using clinical risk factors, hospitals with annual pediatric cardiac surgery volumes of fewer than 100 had significantly higher mortality rates (8.26%) than hospitals with volumes of 100 or more (5.95%), and surgeons with annual volumes of fewer than 75 had significantly higher mortality rates (8.77%) than surgeons with annual volumes of 75 or more (5.90%)., Conclusions: Both hospital volume and surgeon volume are significantly associated with in-hospital mortality, and these differences persist for both high-complexity and low-complexity pediatric cardiac procedures.

Background and Objective: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals., Methods: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology., Results: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat.", Conclusions: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.

This study assesses the relative ability of three different models to predict in-hospital mortality for victims of motor vehicle crashes. The first two models, the trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT), are models that have been used in many earlier studies and have been quoted extensively in the literature. The third model, which is developed in this study, uses essentially the same risk factors as the other two studies, but employs them in a different manner. In order to provide a fair comparison, new (logistic regression) model coefficients are fit to the first two models using the study data. The models are compared with respect to typical criteria for assessing the fit of logistic regression models as well as their ability to predict mortality for various subsets of seriously injured patients. The study concludes that the new model provides a substantially more accurate prediction of mortality, and that it may be wise for regions attempting to assess relative outcomes in their subregions to develop statistical models that are tailored to their own patients.

Objectives: To examine geographical variations in rates of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) in New York State, and to examine variations in the choice between these two procedures., Methods: A retrospective analysis of data from the New York registries for CABG and angioplasty was conducted. Rates were compared for 12 different regions of the state to assess geographic variations. To assess variations in the choice of procedure, frequencies of each procedure by region were compared with expected frequencies obtained by a logistic regression model that related procedure performance to various patient risk factors., Results: There was more than a three-fold variation in age/sex adjusted CABG rates and more than a two-fold variation in age/sex adjusted angioplasty rates among regions. The regional percentages of patients undergoing CABG rather than PTCA ranged from 49% to 70%, and most of the disparity was not related to patient risk factors. Instead, the disparity was largely a result of differences in racial composition and the hospitalization rate for myocardial infarctions., Conclusions: There is considerable regional variation in New York in the tendency to use aggressive cardiac procedures and in the choice of which procedure to use, and these differences are mostly unrelated to patient need.

Objective: To assess the relationship between each of 2 provider volume measures (annual hospital volume and annual cardiologist volume) for percutaneous transluminal coronary angioplasty (PTCA) and 2 outcomes of PTCA (in-hospital mortality and same-stay coronary artery bypass graft [CABG] surgery)., Design: Cohort study, using data from January 1, 1991, through December 31, 1994, from the Coronary Angioplasty Reporting System of the New York State Department of Health., Setting: Thirty-one hospitals in New York State in which PTCA was performed during 1991-1994., Patients: All 62670 patients discharged after undergoing PTCA in these hospitals during 1991-1994., Main Outcome Measures: Rates of in-hospital mortality and CABG surgery during the same stay as the PTCA., Results: The overall in-hospital mortality rate for patients undergoing PTCA in New York during 1991-1994 was 0.90%, and the same-stay CABG surgery rate was 3.43%. Patients undergoing PTCA in hospitals with annual PTCA volumes less than 600 experienced a significantly higher risk-adjusted in-hospital mortality rate of 0.96% (95% confidence interval [CI], 0.91%-1.01%) and risk-adjusted same-stay CABG surgery rate of 3.92% (95% CI, 3.76%-4.08%). Patients undergoing PTCA by cardiologists with annual PTCA volumes less than 75 had mortality rates of 1.03% (95% CI, 0.91%-1.17%) and same-stay CABG surgery rates of 3.93% (95% CI, 3.65%-4.24%); both of these rates were also significantly higher than the rates for all patients. Also, same-stay CABG surgery rates for patients undergoing PTCA in hospitals with annual volumes of 600 to 999 performed by cardiologists with annual volumes of 75 to 174 (2.99%; 95% CI, 2.69%-3.31 %) and 175 or more (2.84%; 95% CI, 2.57%-3.14%) were significantly lower than the overall statewide rate (3.43%)., Conclusions: In New York State, both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.

Objectives: To assess the relative abilities of clinical and administrative data to predict mortality and to assess hospital quality of care for CABG surgery patients., Data Sources/study Setting: 1991-1992 data from New York's Cardiac Surgery Reporting System (clinical data) and HCFA's MEDPAR (administrative data). STUDY DESIGN/SETTING/SAMPLE: This is an observational study that identifies significant risk factors for in-hospital mortality and that risk-adjusts hospital mortality rates using these variables. Setting was all 31 hospitals in New York State in which CABG surgery was performed in 1991-1992. A total of 13,577 patients undergoing isolated CABG surgery who could be matched in the two databases made up the sample., Main Outcome Measures: Hospital risk-adjusted mortality rates, identification of "outlier" hospitals, and discrimination and calibration of statistical models were the main outcome measures., Principal Findings: Part of the discriminatory power of administrative statistical models resulted from the miscoding of postoperative complications as comorbidities. Removal of these complications led to deterioration in the model's C index (from C = .78 to C = .71 and C = .73). Also, provider performance assessments changed considerably when complications of care were distinguished from comorbidities. The addition of a couple of clinical data elements considerably improved the fit of administrative models. Further, a clinical model based on Medicare CABG patients yielded only three outliers, whereas eight were identified using a clinical model for all CABG patients., Conclusions: If administrative databases are used in outcomes research, (1) efforts to distinguish complications of care from comorbidities should be undertaken, (2) much more accurate assessments may be obtained by appending a limited number of clinical data elements to administrative data before assessing outcomes, and (3) Medicare data may be misleading because they do not reflect outcomes for all patients.

Background: Previous studies have shown that the rate of coronary artery bypass graft (CABG) surgery is much higher in New York State than in Ontario., Objective: To compare the service context and clinical characteristics of patients having CABG surgery in New York and Ontario., Design: Retrospective analysis of data from cardiac surgery registries in New York and Ontario., Patients: All 16,690 patients in New York and 5517 patients in Ontario who had isolated CABG surgery in 1993., Measurements: Clinical characteristics of patients having CABG surgery and rates of CABG surgery by coronary anatomy., Results: The overall age-adjusted rate of isolated CABG surgery was 1.79 times (95% CI, 1.74 to 1.85) greater in New York than in Ontario. Patients who had CABG surgery in New York were more likely to be elderly and female and to have recently had myocardial infarction (P < 0.001), whereas patients who had CABG surgery in Ontario were more likely to have had left ventricular dysfunction and severe coronary artery disease (two-vessel disease with proximal left anterior descending disease, three-vessel disease, or left main disease) (P < 0.001). The relative rate of CABG surgery for left main disease was 2.53 times (CI, 2.35 to 2.73) greater in New York than in Ontario but was 8.97 times (CI, 8.01 to 10.06) greater for patients with limited coronary artery disease (one-vessel or two-vessel disease without proximal left anterior descending disease)., Conclusions: The higher rates of CABG surgery in New York are associated with higher rates of CABG surgery among the elderly, women, and patients who recently had myocardial infarction. Potential underservicing in Ontario is suggested by a lower rate of CABG surgery for left main disease; however, the higher rate of CABG surgery in New York is also associated with a strikingly higher rate of surgery in patients with limited coronary disease. Such trade-offs highlight the difficulty of defining an optimal rate of CABG surgery.

Objectives: The purpose of this study was to determine whether performing coronary artery bypass surgery on high-risk patients adversely affects the risk-adjusted mortality rates for patients of surgeons and hospitals in New York State compared with the impact of performing surgery on more routine patients., Methods: Risk-adjusted mortality-rates were calculated for 31 hospitals and 87 surgeons for high-risk (a predicted mortality rate of at least 7.5%) and low-risk patients during the time period 1990 to 1992., Results: The risk-adjusted mortality for all high-risk patients was lower (2.94%) than the risk-adjusted mortality for other patients (3.02%). Fifteen of the 31 hospitals had a lower risk-adjusted mortality for all patients than they did for low-risk patients only, and no differences in either direction were statistically significant. Forty-one of 87 surgeons (47%) had risk-adjusted mortality for all patients that was at least as low as the risk-adjusted mortality for low-risk patients. In general, hospitals and surgeons with the lowest risk-adjusted mortality for all cases also had the lowest risk-adjusted mortality for high-risk cases., Conclusions: The authors conclude that there is no systematic bias against operating on high-risk coronary artery bypass graft patients in the risk-adjusted performance system in New York.

Objectives: The purpose of this consensus effort was to define and prioritize the importance of a set of clinical variables useful for monitoring and improving the short-term mortality of patients undergoing coronary artery bypass graft surgery (CABG)., Background: Despite widespread use of data bases to monitor the outcome of patients undergoing CABG, no consistent set of clinical variables has been defined for risk adjustment of observed outcomes for baseline differences in disease severity among patients., Methods: Experts with a background in epidemiology, biostatistics and clinical care with an interest in assessing outcomes of CABG derived from previous work with professional societies, government or academic institutions volunteered to participate in this unsponsored consensus process. Two meetings of this ad hoc working group were required to define and prioritize clinical variables into core, level 1 or level 2 groupings to reflect their importance for relating to short-term mortality after CABG. Definitions of these 44 variables were simple and specific to enhance objectivity of the 7 core, 13 level 1 and 24 level 2 variables. Core and level 1 variables were evaluated using data from five existing data bases, and core variables only were examined in an additional two data bases to confirm the consensus opinion of the relative prognostic power of each variable., Results: Multivariable logistic regression models of the seven core variables showed all to be predictive of bypass surgery mortality in some of the seven existing data sets. Variables relating to acuteness, age and previous operation proved to be the most important in all data sets tested. Variables describing coronary anatomy appeared to be least significant. Models including both the 7 core and 13 level 1 variables in five of the seven data sets showed the core variables to reflect 45% to 83% of the predictive information. However, some level 1 variables were stronger than some core variables in some data sets., Conclusions: A relatively small number of clinical variables provide a large amount of prognostic information in patients undergoing CABG.

The introduction of coronary stents for the treatment of acute vessel closure has probably improved the safety of angioplasty, but little data are available regarding angioplasty complication rates when bailout stenting is available. Therefore baseline and patient outcome data for 2242 consecutive patients treated at a single tertiary referral center were compared before and after bailout coronary stenting was introduced. Patients treated after stents became available were more likely to have diabetes (16% prestent availability vs 19% poststent, p < 0.05), unstable angina (61% prestent vs 70% poststent, p < 0.01), and to have received intravenous nitroglycerin before the procedure (22% prestent vs 28% poststent, p < 0.01). Major complications occurred in 4.1% of patients before stent availability and 2.0% afterwards (p < 0.01). These complications included in-hospital death (1.1% prestent vs 0.7% poststent, p = not significant [NS]), Q wave myocardial infarction (0.5% prestent vs 0.3% poststent, p = NS), and emergency bypass surgery (2.9% prestent vs 1.1% poststent, p < 0.01). The introduction of coronary stents was associated with a > 50% reduction in major complications despite greater patient acuity. The traditionally reported complication rates for angioplasty appear not to apply when ballout stenting is available.

Objective: To determine if pre-existing conditions significantly improve the ability of current (TRISS and ASCOT) methods for predicting survival of patients with trauma from low falls., Design: Retrospective analysis using logistic regression models to identify significant independent predictors of survival., Setting: Eight hospitals affiliated with New York Medical College., Patients: A total of 1906 patients with trauma from low falls who were admitted to the eight hospitals between July 1987 and June 1989., Main Results: Gender and several pre-existing conditions significantly improved the ability of age and the physiologic and anatomic variables contained in the TRISS and ASCOT methodologies to predict survival for trauma patients suffering from low falls, with males experiencing a lower probability of survival. Odds of survival for patients with these pre-existing conditions ranged from 0.18 to 0.59 times the odds of survival for similar patients without the pre-existing conditions when the TRISS variables were used, and from 0.23 to 0.56 times the odds for similar patients when ASCOT variables were used. Furthermore, some substantial differences were found when hospital performance was assessed with and without the benefit of pre-existing conditions., Conclusions: Pre-existing conditions and male gender are significantly related to survival of patients with trauma from low falls, and should be included along with age and the various physiologic and anatomic measures currently being used to predict survival for those patients.

Objective: To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time., Design: Observation of clinically risk-adjusted operative mortality over time., Setting: All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992., Patients: All 57,187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals., Main Outcome Measures: Actual, expected, and risk-adjusted mortality., Results: Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons (< or = 50 operations per year) experienced a 60% reduction in risk-adjusted mortality in the 4-year period, whereas the highest-volume surgeons (> 150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease., Conclusions: The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).

Objectives: To validate the Trauma and Injury Severity Score (TRISS) and A Severity Characterization of Trauma (ASCOT) models for patients with blunt injuries using an independent trauma registry, and to develop new TRISS and ASCOT models for types of patients with blunt injuries and examine their fit., Design: Retrospective analysis of clinical data from the Institute for Trauma and Emergency Care (ITEC)., Materials and Methods: Statistical models were developed using TRISS and ASCOT variables applied to ITEC data for patients with blunt injuries. These models were compared to Major Trauma Outcome Study (MTOS) models with regard to the resulting coefficients and hospital quality assessments. Also, separate models were developed for different groups of blunt injuries, and these models were compared with one another and tested for adequacy of fit., Measurements and Main Results: ASCOT performed acceptably well when new coefficients were derived using ITEC data, but TRISS did not. Although the models developed from MTOS and from ITEC coefficients generally yielded similar hospital quality assessments, there were some notable exceptions. Some TRISS and ASCOT variables were not significantly related to survival for some subgroups of blunt injuries, and neither the TRISS nor the ASCOT model was an adequate predictor of survival for patients suffering from low falls., Conclusions: New TRISS and ASCOT coefficients should be derived if survival for patients with blunt injuries is to be predicted accurately in independent trauma registries. Also, it may be wise to consider developing separate models for subgroups of patients, particularly if hospitals in the registry have different mixes of patient types.

This study examined changes in the risk-adjusted mortality associated with coronary artery bypass grafting procedures performed in New York State during the first 4 years of New York's Cardiac Surgery Reporting System (1989 to 1992). To track performance over time, surgeons and hospitals were subdivided into three groups on the basis of their performance in 1989. The risk-adjusted mortality for each of the three groups was computed for 1992 and compared with their 1989 mortality. The results indicate that all groups of providers exhibited large reductions in the risk-adjusted mortalities, with the groups that showed the highest initial mortalities manifesting the most improvement. However, the group rankings remained the same in 1992 as they were in 1989. For example, when the hospital groups were based on the terciles of risk-adjusted mortality observed in 1989, the risk-adjusted mortality decreased from 2.72% to 2.19% for group 1, from 4.24% to 2.51% for group 2, and from 7.12% to 2.77% for group 3. Notably, the risk-adjusted mortalities of the three groups were all significantly different from one another in 1989, but were not significantly different from one another in 1992. Another interesting finding was that the volume of operations performed by the various provider groups did not change substantially in the 4-year period.

The purpose of this study was to determine the effect of age on the in-hospital mortality of all 30,972 patients undergoing coronary artery bypass graft (CABG) surgery in New York in 1991 and 1992. Mortality rates were relatively low for patients 40-49, 50-59, and 60-64, 65-69, and 70-74 years old (1.10%, 1.65%, 2.17%, 2.76%, and 3.36%, respectively). However, CABG surgery mortality increased rapidly for patients 75 to 79 years old (5.28%) and patients > or = 80 years old (8.31%). To examine the independent effect of age on mortality after accounting for the effects of other significant risk factors, a multivariate statistical model was developed to identify the significant independent predictors of mortality. Age emerged as 1 of 24 significant predictors, with age > or = 75 demonstrating much higher mortality risk than lesser age. For example, the odds of an 80-year-old patient's dying in the hospital were 3.25 times the odds of a 50-year-old patient's dying in the hospital, assuming all other significant risk factors were identical.

Objective: To assess changes in outcomes of coronary artery bypass graft (CABG) surgery in New York since 1989, when the State Department of Health began collecting, analyzing, and disseminating information regarding risk factors, mortality, and complications of CABG surgery. These new data stimulated specific quality improvement activities at hospitals throughout the state., Design: A clinical database was used to identify significant independent risk factors and to assess risk-adjusted provider mortality rates., Setting: All 30 hospitals performing CABG surgery in New York during the period 1989 through 1992., Patients: All 57,187 patients undergoing isolated CABG surgery who were discharged from New York State hospitals in 1989 through 1992., Main Outcome Measures: Actual, expected (from a logistic regression model), and risk-adjusted in-hospital mortality., Results: Actual mortality decreased from 3.52% in 1989 to 2.78% in 1992. Because average patient severity of illness increased, risk-adjusted mortality decreased even more--a decrease of 41% from 4.17% in 1989 to 2.45% in 1992. The risk-adjustment model performed well; there were no clinically or statistically significant differences between actual and predicted numbers of deaths at any of 10 levels of patient severity., Conclusions: We believe that this quality improvement program, based on the collection and dissemination of risk-adjusted mortality data for CABG surgery, played a significant role in the observed decline in the death rate from this procedure. Quality improvement programs based on similar principles for other procedures and conditions should be undertaken.

Objective: To identify significant independent risk factors for major percutaneous transluminal coronary angioplasty outcomes., Design: Retrospective analysis using univariate and logistic regression analysis to identify significant independent risk factors for adverse outcomes., Setting: All 31 hospitals performing percutaneous transluminal coronary angioplasty in New York State in 1991., Patients: All 5827 patients undergoing percutaneous transluminal coronary angioplasty between January 1, 1991, and June 30, 1991, in New York State., Main Outcome Measures: In-hospital mortality, major complication(s) (in-hospital mortality, myocardial infarction, and/or emergency coronary artery bypass graft), and absence of angiographic success (stenosis reduction of less than 20% on any attempted lesion or residual stenosis of at least 50% on any attempted lesion)., Main Results: Before discharge from the hospital, a total of 37 patients (0.63%) died; 67 patients (1.1%) suffered a myocardial infarction, with a mortality rate of 4.5%; and 97 patients (1.7%) underwent emergency coronary artery bypass graft surgery, with a mortality rate of 2.1% (no deaths in 85 patients who were hemodynamically stable and two deaths among 12 patients who were hemodynamically unstable). A total of 187 patients (3.2%) experienced a major complication. Angiographic success was achieved for 88% of all patients. Multivariate analysis found four independent preprocedural variables related to death: female gender, hemodynamic instability, shock, and ejection fraction., Conclusions: Percutaneous transluminal coronary angioplasty outcomes in New York compare favorably with other recent results reported in the literature. Several preprocedural variables markedly increase the incidence of adverse events.

This study uses New York State hospital discharge data to examine the relationship between in-hospital mortality for a patient receiving an abdominal aortic aneurysm resection and the volume of aneurysm operations performed in the previous year at the hospital where the operation took place and by the surgeon performing the operation. Previous research on this topic is extended in several respects: (1) A three-year data base is used to examine the manner in which hospital and surgeon volume jointly affect mortality rate and to examine ruptured and unruptured aneurysms separately; (2) a six-year data base is used to study the "practice makes perfect" hypothesis and the "selective referral" hypothesis; and (3) the degree of specialization of high-volume surgeons is contrasted with that of other surgeons. The results demonstrate a significant inverse relationship between hospital volume and mortality rate for unruptured aneurysms. Further, very few surgeons substantially increased their aneurysm surgery volumes in the six-year study period. Weak selective referral effects were found for both surgeons and hospitals, and higher-volume aneurysm surgeons tended to have much higher specialization rates.

This study compared the ability of a clinical and administrative data base in New York State to predict in-hospital mortality and to assess hospital performance for coronary artery bypass graft surgery. The results indicated that the clinical data base, the Cardiac Surgery Reporting System, is substantially better at predicting case-specific mortality than the administrative data base, the Statewide Planning and Research Cooperative System. Also, correlations between hospital mortality rates that are risk-adjusted using the two systems were only moderately high (0.75 to 0.80). The addition of new risk factors from the Statewide Planning and Research Cooperative System improved the predictive power of both systems but did not diminish the difference in effectiveness of the two systems. The three unique clinical risk factors in the Cardiac Surgery Reporting System (ejection fraction, reoperation, and more than 90% narrowing of the left main trunk) seemed to account for much of the difference in effectiveness of the two systems.

This study utilized a state-wide data base containing clinical risk factors for cardiac surgery to investigate differences in in-hospital mortality rates for men and women undergoing coronary artery bypass surgery. The crude mortality rates for coronary artery bypass surgery for men and women were 3.08% and 5.43% respectively, in New York State in 1989. When logistic regression analysis was used to control for preoperative risk, gender remained a significant predictor of mortality. Risk-adjusted (indirectly standardized) mortality rates were 3.33% and 4.45% for men and women, respectively. The risk-adjusted odds ratio of women to men experiencing in-hospital death was 1.52 (95% confidence interval 1.25 to 1.90).

This study uses a new database containing clinical risk factors for cardiac surgery to investigate the relationship between surgical volume (hospital and surgeon) and inhospital mortality rate for all patients receiving coronary artery bypass surgery in New York State in 1989. Also, hospitals with significantly higher and lower mortality rates than expected on the basis of patient preoperative risk factors are identified. The results demonstrate that both annual surgeon volume and annual hospital volume are significantly (inversely) related to mortality rate. The 36% of all coronary bypass operations performed in hospitals with annual bypass volumes of 700 or more by surgeons with annual bypass volumes of 180 or more had a risk-adjusted mortality rate of 2.67% in comparison to a risk-adjusted mortality rate of 4.29% for other bypass operations. Furthermore, low surgical volumes were a major contributor to the outlier status of four of the five hospitals with significantly higher mortality rates than expected.

This study examines black/white differences in the utilization of three cardiac procedures (coronary angiography, coronary artery bypass graft, and coronary angioplasty) for patients hospitalized with coronary artery disease in New York State in the first 6 months of 1987. In contrast with previous studies, disease stages are used to control for severity of illness in addition to various severity proxies. Another methodological difference is that patient episodes (a fixed period of time after an initial hospital admission) are used as the unit of analysis rather than discharges to accurately account for patients whose initial visit is to a hospital not certified to perform the procedure. After controlling for severity using logistic regression analysis, whites were found to undergo significantly more of each of the procedures than blacks (odds ratios of 1.25, 2.06, and 1.69 for angiography, bypass graft, and angioplasty, respectively). These significant differences existed for most levels of the various control variables.

The need for quality assurance in vascular surgery can be deduced from the variability in unruptured abdominal aneurysm operative death rates in a group of patients large enough that factors influencing mortality rates other than quality of care can be controlled. Operative mortality rate for 3570 patients undergoing unruptured abdominal aortic aneurysm repair was determined for all non-Veterans Administration surgeons and hospitals in New York State from 1985 to 1987. The average annual number of aneurysm operations per surgeon was 3.6, and per hospital it was 10.2. Unruptured aneurysm repair mortality for surgeons performing 1 to 5 aneurysm operations per year was 10% whereas for surgeons performing more than 26 aneurysm operations per year it was 6% (p less than 0.0001). Unruptured aneurysm repair mortality for hospitals performing 1 to 5 aneurysm operations per year was 14% and for hospitals performing more than 38 aneurysm operations per year it was 5% (p less than 0.0001). Even when these mortality rates were adjusted for differences in patient age, severity of illness, secondary diagnoses and admission status, significant mortality rate differences persisted: 9% versus 4% for low and high volume surgeons, respectively (p less than 0.001), and 12% versus 5% for low and high volume hospitals, respectively (p less than 0.001). Surgeons who performed more than 7 aneurysm operations per year devoted more of their practice to aortic (11%) and vascular operations (52%) than did surgeons who performed 7 or fewer aneurysm operations per year (2% and 19%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

This study analyzes data from New York State's new Cardiac Surgery Reporting System, which contains information about cardiac preoperative risk factors, postoperative complications, and hospital discharge. The purposes of the study were to determine the set of significant clinical risk factors and to identify cardiac surgical centers most likely to have serious quality-of-care problems. Significant risk factors for in-hospital death were age, gender, ejection fraction, previous myocardial infarction, number of open heart operations in previous admissions, diabetes requiring medication, dialysis dependence, disasters (acute structural defect, renal failure, cardiogenic shock, gunshot), unstable angina, intractable congestive heart failure, left main trunk narrowed more than 90%, and type of operation performed. Four of the 28 hospitals had significantly higher mortality rates than expected, given the risk factors of their patients. Subsequent site visits and medical record reviews confirmed that these facilities had high percentages of quality-of-care problems among cases resulting in mortality.

Presently a survey document is used in New York State to enforce Federal and State regulatory standards for long term care facilities (skilled nursing facilities and related facilities). This document is used to establish Medicare and Medicaid certification for these facilities. This study describes the creation of a new survey process---a first stage consisting of a screening survey followed, if necessary, by an intensive survey. A priority assignment model which utilizes the judgments of experts from the New York State Office of Health Systems Management (OHSM) has been developed. This model is employed to develop ranks, priority weights and classifications for the various standards and the Federal conditions which the standards comprise (as well as equivalent State regulations). Saaty's Analytical Hierarchy Process is used to obtain the ranks and priority weights. The consistency of the experts' judgements is measured using Kendall's coefficient of agreement. An optimal split algorithm is used to subdivide the standards and conditions according to impact (high, moderate or low) on patient care, health and safety. The results are to be used as a management tool in developing decision rules for defining the scope of the intensive survey on the basis of screening survey results.