RESUMO
OBJECTIVE: The aim of this study was to determine whether surgery and anesthesia in the elderly may promote Alzheimer disease and related dementias (ADRD). BACKGROUND: There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations. METHODS: A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the ''Appendectomy'' treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD. RESULTS: The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 [95% confidence interval (CI) 0.94-0.98], P < 0.0001, (28.2% in Appendectomy vs 29.1% in controls, at 7.5 years). The HR for death was 0.97 (95% CI 0.95-0.99), P = 0.002, (22.7% vs 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (95% CI 0.86-0.92), P < 0.0001, (7.6% in Appendectomy vs 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group. CONCLUSION: In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.
Assuntos
Doença de Alzheimer , Anestesia , Apendicite , Disfunção Cognitiva , Idoso , Doença de Alzheimer/diagnóstico , Doença de Alzheimer/epidemiologia , Apendicite/cirurgia , Humanos , Medicare , Estados UnidosRESUMO
OBJECTIVE: To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity. BACKGROUND: Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood. METHODS: A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined. RESULTS: In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)). CONCLUSIONS: Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.
Assuntos
Competência Clínica , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Medicare , Avaliação de Resultados em Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Estados UnidosRESUMO
OBJECTIVE: The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA: In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS: We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS: Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9âmin; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS: Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.
Assuntos
Competência Clínica , Admissão e Escalonamento de Pessoal/tendências , Procedimentos Cirúrgicos Operatórios/educação , Procedimentos Cirúrgicos Operatórios/mortalidade , Tolerância ao Trabalho Programado , Algoritmos , Educação de Pós-Graduação em Medicina , Feminino , Mortalidade Hospitalar/tendências , Humanos , Internato e Residência , Masculino , Medicare , Estados UnidosRESUMO
OBJECTIVE: To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics. BACKGROUND: Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear. METHODS: A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery. RESULTS: In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals. CONCLUSIONS: Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.
Assuntos
Economia Hospitalar , Custos Hospitalares , Hospitais de Ensino/economia , Procedimentos Cirúrgicos Operatórios/economia , Idoso , Custos e Análise de Custo , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Procedimentos Cirúrgicos Operatórios/mortalidade , Estados UnidosRESUMO
BACKGROUND: Coronary atherosclerosis raises the risk of acute myocardial infarction (AMI), and is usually included in AMI risk-adjustment models. Percutaneous coronary intervention (PCI) does not cause atherosclerosis, but may contribute to the notation of atherosclerosis in administrative claims. We investigated how adjustment for atherosclerosis affects rankings of hospitals that perform PCI. METHODS AND RESULTS: This was a retrospective cohort study of 414 715 Medicare beneficiaries hospitalized for AMI between 2009 and 2011. The outcome was 30-day mortality. Regression models determined the association between patient characteristics and mortality. Rankings of the 100 largest PCI and non-PCI hospitals were assessed with and without atherosclerosis adjustment. Patients admitted to PCI hospitals or receiving interventional cardiology more frequently had an atherosclerosis diagnosis. In adjustment models, atherosclerosis was associated, implausibly, with a 42% reduction in odds of mortality (odds ratio=0.58, P<0.0001). Without adjustment for atherosclerosis, the number of expected lives saved by PCI hospitals increased by 62% (P<0.001). Hospital rankings also changed: 72 of the 100 largest PCI hospitals had better ranks without atherosclerosis adjustment, while 77 of the largest non-PCI hospitals had worse ranks (P<0.001). CONCLUSIONS: Atherosclerosis is almost always noted in patients with AMI who undergo interventional cardiology but less often in medically managed patients, so adjustment for its notation likely removes part of the effect of interventional treatment. Therefore, hospitals performing more extensive imaging and more PCIs have higher atherosclerosis diagnosis rates, making their patients appear healthier and artificially reducing the expected mortality rate against which they are benchmarked. Thus, atherosclerosis adjustment is detrimental to hospitals providing more thorough AMI care.
Assuntos
Doença da Artéria Coronariana/terapia , Infarto do Miocárdio/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Intervenção Coronária Percutânea/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Feminino , Nível de Saúde , Humanos , Masculino , Medicare , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: To develop a method to allow a hospital to compare its performance using its entire patient population to the outcomes of very similar patients treated elsewhere. DATA SOURCES/SETTING: Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006. STUDY DESIGN: Using two example "focal" hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals. DATA COLLECTION/EXTRACTION METHODS: All patients were used at each focal hospital, and we found the 10 closest matched patients from control hospitals with exactly the same principal procedure as each focal patient. PRINCIPAL FINDINGS: We achieved exact matches on all procedures and very close matches for other patient characteristics for both hospitals. There were few to no differences between each hospital's patients and their matched control patients on most patient characteristics, yet large and significant differences were observed for mortality, failure-to-rescue, and cost. CONCLUSION: Indirect standardization matching can produce fair audits of quality and cost, allowing for a comprehensive, transparent, and relevant assessment of all patients at a focal hospital. With this approach, hospitals will be better able to benchmark their performance and determine where quality improvement is most needed.
Assuntos
Custos Hospitalares/estatística & dados numéricos , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/tendências , Qualidade da Assistência à Saúde/estatística & dados numéricos , Benchmarking/métodos , Humanos , Illinois , Modelos Estatísticos , New York , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Risco , Texas , Estados UnidosRESUMO
OBJECTIVE: Develop an improved method for auditing hospital cost and quality tailored to a specific hospital's patient population. DATA SOURCES/SETTING: Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, New York, and Texas between 2004 and 2006. STUDY DESIGN: A template of 300 representative patients from a single index hospital was constructed and used to match 300 patients at 43 hospitals that had a minimum of 500 patients over a 3-year study period. DATA COLLECTION/EXTRACTION METHODS: From each of 43 hospitals we chose 300 patients most resembling the template using multivariate matching. PRINCIPAL FINDINGS: We found close matches on procedures and patient characteristics, far more balanced than would be expected in a randomized trial. There were little to no differences between the index hospital's template and the 43 hospitals on most patient characteristics yet large and significant differences in mortality, failure-to-rescue, and cost. CONCLUSION: Matching can produce fair, directly standardized audits. From the perspective of the index hospital, "hospital-specific" template matching provides the fairness of direct standardization with the specific institutional relevance of indirect standardization. Using this approach, hospitals will be better able to examine their performance, and better determine why they are achieving the results they observe.
Assuntos
Benchmarking/métodos , Auditoria Financeira/métodos , Custos Hospitalares/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Illinois , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , New York , Texas , Estados UnidosRESUMO
OBJECTIVE: Develop an improved method for auditing hospital cost and quality. DATA SOURCES/SETTING: Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, Texas, and New York between 2004 and 2006. STUDY DESIGN: A template of 300 representative patients was constructed and then used to match 300 patients at hospitals that had a minimum of 500 patients over a 3-year study period. DATA COLLECTION/EXTRACTION METHODS: From each of 217 hospitals we chose 300 patients most resembling the template using multivariate matching. PRINCIPAL FINDINGS: The matching algorithm found close matches on procedures and patient characteristics, far more balanced than measured covariates would be in a randomized clinical trial. These matched samples displayed little to no differences across hospitals in common patient characteristics yet found large and statistically significant hospital variation in mortality, complications, failure-to-rescue, readmissions, length of stay, ICU days, cost, and surgical procedure length. Similar patients at different hospitals had substantially different outcomes. CONCLUSION: The template-matched sample can produce fair, directly standardized audits that evaluate hospitals on patients with similar characteristics, thereby making benchmarking more believable. Through examining matched samples of individual patients, administrators can better detect poor performance at their hospitals and better understand why these problems are occurring.