Regionalization of the Surgical Care of Children: A Risk-Adjusted Comparison of Hospital Surgical Outcomes by Geographic Markets

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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS out of 18 symptoms. This difference reached statistical significance for four symptoms: anxiety, constipation, thirst, and polyuria (Figure 1). By the 6 months timepoint, these differences had resolved and symptom improvement was similar in the ePTH and the nPTH groups. Conclusions: Elevated PTH after curative PTX may result in a delay in symptom improvement at 6 weeks for nonspecific symptoms of PHPT, but this difference resolves by 6 months.

23.5. The Safety of Laparoscopic versus Open Ventral Hernia Repair in 23,327 Morbidly Obese Patients. S. Qiu,1 L. M. Doyon,1 C. M. Divino1; 1Mount Sinai School Of Medicine, New York, NY, USA

23.4. PTH Elevation After Curative Parathyroidectomy Delays Symptom Improvement. P. Pathak,1 S. Holden,1 S. Schaefer,1 G. Leverson,1 H. Chen,1 R. S. Sippel1; 1University Of Wisconsin, Madison, WI, USA Introduction: Curative parathyroidectomy for primary hyperparathyroidism (PHPT) has been shown to resolve various nonspecific symptoms related to the disease. Between 8 to 40% of patients with normocalcemia after curative resection have elevated parathyroid hormone levels (ePTH) at follow-up. We investigated whether ePTH in the early post-operative period was associated with the timing of symptom improvement. Methods: This prospective study included adult patients with PHPT who underwent curative parathyroidectomy from November 2011 to September 2012. Biochemical testing at 2 weeks post-operatively identified ePTH versus normal PTH (nPTH). A questionnaire administered pre- and post-operatively at 6 weeks and 6 months asked patients to rate the frequency of 18 symptoms of PHPT on a 5-point Likert scale, ranging from never to very frequently. Statistical analysis was performed on the change in scores for individual symptoms. Results: Of 194 patients that underwent parathyroidectomy for PHPT, 129 (66%) participated in the study. Pre-operatively, all patients endorsed having at least one or more symptom(s), with a mean of 136 4 symptoms. We separated patients into nPTH and ePTH groups by serum PTH. At two weeks, 20 patients (16%) had ePTH. The percentage of patients who showed post-operative improvement for individual symptoms was compared between groups. At the early timepoint (6 weeks), the ePTH group showed less improvement in 14

Introduction: Ventral hernia repair is one of the most common general surgery procedures. As the obesity epidemic spreads in the US population–with nearly 9% of people having a BMI of 35 or higher–a larger percentage of these surgical patients are now not just obese, but morbidly obese. With obesity being a known risk factor for ventral hernias, it becomes important to determine the optimal operative approach in this patient population. This study compares 30-day outcomes in morbidly obese patients undergoing laparoscopic versus open ventral herniorrhaphy. Methods: Using the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, morbidly obese patients (BMI>¼35) who underwent ventral herniorrhaphy were identified. Patients were then divided into cohorts based on laparoscopic or open repair. Coarsened Exact Matching, a nonparametric matching algorithm, was used to minimize treatment selection bias. This method improves the estimation of causal effects by reducing imbalance in covariates between cohorts; the groups were matched based on adjustment for all 41 baseline risk factors. Pre-operative characteristics and post-operative outcomes were then compared in the matched cohort using SPSS v.20. Results: The final, matched cohort of 23,327 patients (77% open, 23% laparoscopic) had no difference in pre-operative characteristics. All types of surgical site infections (SSI) were less likely to occur in patients undergoing laparoscopic repair relative to open repair (superficial: odds ratio (OR), 0.26; 95% confidence interval (CI) 0.20-0.34; deep: OR, 0.14; 95% CI, 0.08-0.26; organ space: OR, 0.47; 95% CI, 0.28-0.76). Wound disruption and sepsis were lower for laparoscopic patients (wound disruption: OR, 0.28; 95% CI, 0.14-0.56; sepsis: OR, 0.44; 95% CI, 0.30-0.66; p<0.0001). Both groups had equivalent odds of mortality, pulmonary embolism, acute renal failure, and myocardial infarction. Lastly, patients undergoing open repair were more likely to return to the OR within 30 days post surgery (open vs. laparoscopic: 2.5% vs. 1.4%; p<0.0001). Conclusions: Laparoscopic ventral herniorrhaphy in morbidly obese patients is associated with lower risk of SSI, wound disruption, sepsis, and 30-day re-operation relative to open repair, with no difference in rate of major complications.

23.6. Regionalization of the Surgical Care of Children: A RiskAdjusted Comparison of Hospital Surgical Outcomes by Geographic Markets. J. H. Salazar,1 S. Goldstein,1 J. Yang,1 J. Douaiher,1 K. Al-Omar,1 J. Aboagye,1 F. Abdullah1; 1Johns Hopkins University School Of Medicine - Pediatric Surgery, Baltimore, MD, USA

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS Introduction: The US is facing a crisis of healthcare allocation and expenditures. Resources are increasingly limited and there is simultaneous greater scrutiny of clinical outcomes. High-quality healthcare at reasonable cost is paramount. There is an ongoing debate among pediatric surgeons regarding the need or lack thereof to centralize the surgical care of children to high volume children’s’ centers. Risk-adjusted comparisons of hospitals with pediatric surgery capabilities are needed to assist in developing optimal national models of care delivery. Methods: Admissions from five non-overlapping years of the Kids’ Inpatient Database (KID) and the National Inpatient Sample (NIS) from 2006 to 2010 were analyzed. Only patients 0-18 years undergoing one of 500 common non-cardiac surgical procedures were included. Traumatic injuries and patients transferred between facilities were excluded. Risk-adjustment was performed with a validated ICD-9 code based tool and scores of 0-10 were assigned according to the patient’s mortality risk. Hospitals were grouped into metropolitan regions using the first three digits of their zip code. Poorly performing hospitals were defined by an odds ratio (OR) >1 and p value <0.05 for mortality when compared to the center with the highest pediatric surgical volume in that same region. Results: Information was obtained from 599,853 pediatric surgical admissions and 174 hospitals in 73 regions were amenable to statistical comparison. Each included region contained multiple hospitals (range 2-30) that provided pediatric surgical care. A total of 21 (12.1%) poor performing hospitals (OR range 1.5-26) in 16 regions were identified. Twenty (95.2%) were teaching hospitals, 14 (66.7%) were large (per the NIS and KID definition) and 11 (52.4%) were located on regions from the west coast. Only five hospitals in the country (2.9%) performed significantly better (OR <1) when compared to their respective large-volume reference hospitals. Conclusions: The present analysis is a novel risk-adjusted assessment of the performance of hospitals delivering pediatric surgical care. We identified 21 poorly performing hospitals in 16 metropolitan regions when compared to the largest pediatric volume hospital in that area. This study provides valuable data for discussion as healthcare delivery systems continue to debate optimal resource distribution and regionalization of the surgical care of children.

23.7. Clinical Registry and Administrative Claims Data Disagree on Quality of Surgical Care for Elderly Patients. E. H. Lawson,1,2 D. S. Zingmond,4 C. Y. Ko1,2,3; 1University Of California - Los Angeles - Department Of Surgery, Los Angeles, CA, USA; 2American College Of Surgeons - Division Of Research And Optimal Patient Care, Chicago, IL, USA; 3 VA Greater Los Angeles Healthcare System - Department Of Surgery, Los Angeles, CA, USA; 4University Of California - Los Angeles - Department Of Medicine, Los Angeles, CA, USA Introduction: Hospitals’ quality of care for elderly surgical patients is publically reported using measures focused on postoperative complications. There is debate regarding the optimal data source for such measures. The objective of this study was to compare the performance of clinical registry versus administrative claims data for measuring hospital quality of care for elderly patients undergoing surgical procedures. Methods: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims data. A National Quality Forum endorsed risk-adjusted composite measure of 30-day postoperative major complications and/or death was used to assess hospital quality using ACS-NSQIP data versus Medicare claims data. This measure uses hierarchical multivariable logistic regression modeling to identify statistically significant outliers for better or worse hospital performance. Agreement on hospital quality between the data sources was assessed using kappa statistics. Results: 111,984 patients from 206 hospitals

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were studied. Using ACS-NSQIP data, 21.8% of patients had a major postoperative complication and/or death, compared to 30.0% using Medicare claims data (p<0.05). There was moderate agreement between the data sources on the patient-level occurrence of the composite outcome (kappa 0.56). ACS-NSQIP data identified 23 hospitals as having statistically significant worse than expected performance and 20 as having statistically significant better than expected performance. Amongst these hospitals, 4 and 9 were also identified as having worse or better performance than expected using Medicare claims data, respectively. Agreement between the data sources on risk-adjusted hospital outlier status was poor (weighted kappa 0.21), as was agreement on hospital decile rank for performance (weighted kappa 0.21). Conclusions: Assessment of hospital quality of care for elderly patients undergoing surgical procedures differs substantially when using a clinical registry data source versus administrative claims data. These findings have implications for surgical quality measures currently being considered for public reporting and valuebased purchasing.

23.8. Is Incisional Hernia Reoperation a Long term Quality Indicator In General Surgery? A. M. Stey,2 M. McGoryRussell,2 M. Maggard-Gibbons,2 E. H. Lawson,2 R. Merkow,1 R. Louie,2 D. Zingmond,2 B. L. Hall,1,3 C. Y. Ko1,2; 1American College Of Surgeons - Division of Research And Optimal Patient Care, Chicago, IL, USA; 2University Of California Los Angeles - David Geffen School Of Medicine, Los Angeles, CA, USA; 3Washington University - Division of General Surgery, St. Louis, MO, USA Introduction: Although the National Surgery Quality Improvement Program (NSQIP) collects rigorous clinical data up to 30 days postoperatively, occurrences after 30 days are not captured. As a result, postoperative complications after 30 days are understudied. It is unclear whether it is possible to reliably compare hospitals on risk adjusted events after 30 days. Medicare has limited clinical data but reliably captures major events such as procedures from enrollment until death. Incisional hernia repair is an important event after abdominal surgery, and may be a proxy for quality of the index operation. The aim was to determine whether incisional hernia repair at 6 months following common abdominal operations could be used to meaningfully compare hospital quality. Methods: Common abdominal operations (small bowel resection (SBR), ventral hernia repair (VHR), colectomy, pancreatic resection or cholecystectomy; laparoscopic or open) were identified in the 2005-2008 NSQIP/Medpar linked dataset. The follow up time of 6 months was selected to capture the majority of incisional hernia repairs but avoid capturing unrelated events. NSQIP demographic (age & gender) and clinical variables (ASA class, functional status, medical comorbidities, body mass index & smoking status were used to risk adjust the occurrence of incisional hernia repair. Hospitals were ranked based on risk adjusted odds ratio of incisional hernia repair using a mixed effects logistic model. Operative time, length of stay, surgical site infection (SSI) and composite morbidity (dichotomous variable of whether any postoperative cardiac, dvt, pneumonia, reintubation, ssi, bleeding or renal complications occurred) were compared between high and low outliers using wilcoxon rank sum and chi square test. Results: 35,525 patients underwent SBR,VHR, colectomy, pancreatic resection or cholecystectomy in 216 hospitals. Of those, 9% of patients underwent an incisional hernia repair. 64% incisional hernia repairs occurred by 6 months postoperatively. After risk adjustment, 4 hospitals were identified as low outliers. 5 hospitals were identified as high outliers (Figure). Low outlier hospitals had significantly lower rates of 30 day deep ssi than high outliers (0.4% vs. 1.9%, p¼0.005). Low outlier hospitals also had lower rates of composite 30 day morbidity (19.6% vs. 27.5%, p¼<0.0001), as well as shorter index operative times (126 vs. 181 minutes, p<0.0001), and index length of stay (8 vs. 9 days, p<0.0001). Conclusions: Merged