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Safety-Net Burden Affects Cost and Outcomes at Academic Hospitals
Vol. 221, No. 4S1, October 2015
Scientific Forum Abstracts
95% CI, 3.11e3.53; (3+) OR 4.99, 95% CI, 4.64e5.37 had higher odds of accessing acute care after surgery. CONCLUSIONS: Significant predictors of acute care at 7 days after operation in freestanding ASCs in South Carolina were African-American race and CCI scores >0. As the operative volume in freestanding ASCs rises, further research is needed on the safety and efficiency of surgery in this environment. Postoperative Readmission Time Interval and Model Performance: Implications for Hospital Profiling Andrew A Gonzalez, MD, JD, MPH, Aslam Ejaz, MD, MPH, Nicholas H Osborne, MD, Amir A Ghaferi, MD, FACS University of Michigan, Ann Arbor, MI; University of Illinois at Chicago, Chicago, IL INTRODUCTION: Despite growing popularity in pay-for-performance programs, 30-day readmissions have been widely criticized for being unable to distinguish high- vs low-quality hospitals. This may, in part, stem from the arbitrary selection of a 30-day time interval. It remains unknown if the use of other intervals would improve the ability to profile hospitals on postoperative readmissions. METHODS: This retrospective study of national Medicare data (2005 to 2009) included 2,540,694 patients undergoing 1 of 10 high-risk surgical procedures. We used logistic regression to model the probability of being readmitted at the following intervals from discharge: 1-30 days, 1-5 days, 1-10 days, 1-15 days, 6-10 days, 11-15 days, and 16-30 days. We evaluated model performance using pseudo-R2 (a measure of explained variability), c-statistics (the ability of the model to predict the outcome), and year-to-year reliability (a measure random variation unassociated with quality). Our models adjusted for traditional patient-level variables available in administrative data: demographics, comorbidities, complications, and operation performed.
S131
CONCLUSIONS: Profiling hospital readmissions using a 30-day interval may be suboptimal due to either factors unmeasured in administrative datasets or random variation. Model performance might be improved by shortening the interval to 5 or 10 days. Redesigned Electronic Medical Notes Allow Automated Clinical Data Extraction and Decrease Provider Documentation Time Jose G Christiano, MD University of Rochester Medical Center, Rochester, NY INTRODUCTION: Over the last few years, widespread implementation of electronic medical records (EMR) has increased the burden of documentation on providers. Nevertheless, retrieval of meaningful data from EMR for research or quality control purposes continues to be mostly renegaded to individual chart review and/or manual entry in databanks. We hypothesized that standard EMR notes could be redesigned to provide customary documentation and allow automated clinical data retrieval by commercially available text data extraction software (TDES), with minimal disruption to provider workflow (documentation time). METHODS: Twenty fictitious patients undergoing reduction mammoplasty were created. Fictitious encounters included initial consultation, preoperative visit, operation, and postoperative visits at 1, 8, and 25 weeks. Each encounter was documented with our previous standard note (SN) and a redesigned “data-friendly” note (DFN). Documentation time was measured and compared between the 2 note groups. All DFNs were then exported in PDF format and fed into a TDES for data accrual. Seventy-six variables were assigned for monitoring and retrieval, spanning from patient demographics, to elements of the history and physical, to operative details, to clinical outcomes.
RESULTS: Model performance decreased with lengthening readmission intervals (Table). For example, 5-day readmissions performed better than 30-day readmissions on all statistical tests: 0.080 vs 0.052 (pseudoR2), 0.71 vs 0.66 (c-statistic), 0.54 vs 0.47 (next-year reliability).
RESULTS: The TDES successfully analyzed all 120 DFNs (300 pages) in less than 10 seconds, generating a database containing 4,850 clinical data points. Total documentation time per patient was found to be less in the DFN group (20.51.5 min) than in the SN group (21.3 1.6 min), reaching statistical significance (p<0.01).
Table. Model Performance and Reliability of Individual Readmission Measures
CONCLUSIONS: Redesigned “data-friendly” EMR notes allow automated clinical data retrieval by commercially available text data extraction software and decrease provider documentation time.
Logistic regression model performance
Year-to-year reliability* Readmissions % of 2005-07 2005-07 measure patients Pseudo-R2 c-statistic vs 2008 vs 2009
30-d 1-5 d 1-10 d 1-15 d 6-10 d 11-15 d 16-30 d
17.8 8.7 11.5 13.6 2.9 2.1 4.1
0.052 0.080 0.060 0.055 0.016 0.014 0.018
0.66 0.71 0.68 0.67 0.62 0.61 0.61
0.47 0.54 0.51 0.50 0.03 0.01 0.02
0.41 0.47 0.44 0.42 0.03 0.00 0.03
*The square of the coefficient of correlation between readmission rates assessed in each timeframe.
Safety-Net Burden Affects Cost and Outcomes at Academic Hospitals Richard S Hoehn, MD, Koffi Wima, Matthew A Vestal, MHA, Drew J Weilage, MHA, Daniel E Abbott, MD, FACS, Vishad Y Nabili, MD University of Cincinnati, Cincinnati, OH; Sg2 Health Care and Hospital System Consultancy, Chicago, IL; Centura Health, Denver, CO INTRODUCTION: Hospital safety-net burden is known to correlate with inferior patient outcomes. The aim of this study was to assess the influence of patient and hospital factors on these outcomes.
S132
J Am Coll Surg
Scientific Forum Abstracts
METHODS: Patients undergoing 9 major surgical procedures from 2009 to 2012 were queried using the University HealthSystem Consortium. Hospitals (n¼231) were grouped according to safety-net burden (proportion of Medicaid/uninsured charges for all 12,638,166 patient encounters). Surgical procedure patient cohorts were examined for preoperative characteristics, postoperative outcomes, and resource use. Gamma regression was used to analyze the effect of patient and center characteristics on surgical outcomes and costs. Medicare Hospital Compare data was used to characterize the groups of hospitals. RESULTS: For all procedures examined, patients at high safety-net burden hospitals (HBH) were most likely youngest, of black race, and had lowest socioeconomic status, highest severity of illness, and highest cost for surgical care. For most procedures, HBH also had the most emergent cases, longest length of stay, highest mortality, and highest readmissions. After adjusting for patient characteristics and hospital procedure-specific volume, HBH were still 6% to 26% more expensive than low safety-net burden hospitals (Table, all p<0.001). Analysis of Medicare data found HBH had worse performance on SCIP measures, more surgical complications, and inferior markers of emergency department timeliness and efficiency.
Procedure
Coronary artery bypass grafting Colectomy Esophagectomy Hip replacement Kidney transplant Knee replacement Pancreaticoduodenectomy Pulmonary lobectomy Ventral hernia repair
Risk ratio adjusted for Risk ratio patient adjusted for factors and Risk ratio patient hospital unadjusted factors volume
1.12 1.68 1.44 1.37 1.11 1.30 1.31 1.50 1.25
1.06 1.23 1.27 1.27 1.13 1.25 1.20 1.23 1.10
1.06 1.21 1.26 1.12 1.12 1.09 1.20 1.16 1.10
CONCLUSIONS: These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost. This is likely due to hospital resources, and impending changes to reimbursement may further affect the quality of surgical care at these centers. Sharps Injuries in the Operating Room Sterile Fields of an Academic Tertiary Care Center Naveen F Sangji, MD, MPH, Sandra Silvestri, RN, Evelyn Abayaah, David C Chang, PhD, MBA, MPH, Matthew M Hutter, MD, MPH, FACS, Catherine O’Malley, RN, MSN Massachusetts General Hospital, Boston, MA INTRODUCTION: Data on the prevalence and distribution of operating room (OR) sterile field sharps injuries sustained by
attending surgeons, residents, scrub nurses, and surgical (scrub) technologists are limited. We attempted to understand current sharps handling practices, injuries, and reporting behavior among the OR staff at our academic center to identify interventions that may improve sterile field sharps safety and reporting. METHODS: An electronic survey with questions pertaining to sharps handling practices, injuries, and reporting was emailed to 864 staff members between July and September 2014. Two reminders were sent. Adjusting for practice years and safety training, analysis for risk of injury was performed relative to attending surgeons. RESULTS: The overall response rate was 49% (n ¼426), with 368 completed surveys. Of the respondents, 163 (44%) reported a total of 434 injuries in the preceding 3 years. Attending surgeons and residents comprised 65% of injured staff and sustained 69% of the total injuries. Residents had a similar likelihood of injury (odds ratio [OR] 0.9, 95% CI, 0.37-2.2); scrub nurses (OR 0.3, 95% CI, 0.17-0.54) and technologists (OR 0.3, 95% CI, 0.140.76) had a lower likelihood. Half of those injured reported to Occupational Health Service (OHS). Scrub technologists were most likely to report (OR 15, 95% CI, 3.3-69.7). Of those who did not report, 46% stated time as a limiting factor. CONCLUSIONS: Attending surgeons and residents sustain the majority of sterile field sharps injuries and are the least likely to report them. Interventions include standardization of sharps handling, shorter safety reports, and an on-site OHS presence to expedite the reporting process. Significant Variation in Surgical Supply Cost Secondary to Surgeon Preference for Laparoscopic Cholecystectomy Michelle C Nguyen, MD, Matthew J Luzum, MD, David B Renton, MD, FACS, Gary S Phillips, Susan D Moffatt-Bruce, MD, PhD, FACS Ohio State University Wexner Medical Center, Columbus, OH INTRODUCTION: Variation in surgical supply use among surgeons can lead to unwarranted increased costs within operating rooms (OR). The aim of this study was to determine the surgical supply cost variation among surgeons performing laparoscopic cholecystectomies (LCs). METHODS: Surgical supply cost data were collected retrospectively from financial accounting, inclusive of all surgeons performing consecutive single procedure LCs from November 1, 2011 to February 1, 2015. Surgeons with fewer than 5 LCs within the study period were excluded. Use of trocars, scissors, clips, skin closure materials, drapes, hemostatic agents, suction irrigators, and specimen retrieval bags were selected for analysis. RESULTS: A total of 1,252 cases were performed by 20 surgeons. The surgical supply cost varied widely, from $346 to $2,829. The median supply cost was $818 (Figure). Patient age and sex did not affect the mean cost in a statistically significant way (p¼0.534 and 0.150, respectively). Variation between surgeon preference in supply use
Scientific Forum Abstracts
95% CI, 3.11e3.53; (3+) OR 4.99, 95% CI, 4.64e5.37 had higher odds of accessing acute care after surgery. CONCLUSIONS: Significant predictors of acute care at 7 days after operation in freestanding ASCs in South Carolina were African-American race and CCI scores >0. As the operative volume in freestanding ASCs rises, further research is needed on the safety and efficiency of surgery in this environment. Postoperative Readmission Time Interval and Model Performance: Implications for Hospital Profiling Andrew A Gonzalez, MD, JD, MPH, Aslam Ejaz, MD, MPH, Nicholas H Osborne, MD, Amir A Ghaferi, MD, FACS University of Michigan, Ann Arbor, MI; University of Illinois at Chicago, Chicago, IL INTRODUCTION: Despite growing popularity in pay-for-performance programs, 30-day readmissions have been widely criticized for being unable to distinguish high- vs low-quality hospitals. This may, in part, stem from the arbitrary selection of a 30-day time interval. It remains unknown if the use of other intervals would improve the ability to profile hospitals on postoperative readmissions. METHODS: This retrospective study of national Medicare data (2005 to 2009) included 2,540,694 patients undergoing 1 of 10 high-risk surgical procedures. We used logistic regression to model the probability of being readmitted at the following intervals from discharge: 1-30 days, 1-5 days, 1-10 days, 1-15 days, 6-10 days, 11-15 days, and 16-30 days. We evaluated model performance using pseudo-R2 (a measure of explained variability), c-statistics (the ability of the model to predict the outcome), and year-to-year reliability (a measure random variation unassociated with quality). Our models adjusted for traditional patient-level variables available in administrative data: demographics, comorbidities, complications, and operation performed.
S131
CONCLUSIONS: Profiling hospital readmissions using a 30-day interval may be suboptimal due to either factors unmeasured in administrative datasets or random variation. Model performance might be improved by shortening the interval to 5 or 10 days. Redesigned Electronic Medical Notes Allow Automated Clinical Data Extraction and Decrease Provider Documentation Time Jose G Christiano, MD University of Rochester Medical Center, Rochester, NY INTRODUCTION: Over the last few years, widespread implementation of electronic medical records (EMR) has increased the burden of documentation on providers. Nevertheless, retrieval of meaningful data from EMR for research or quality control purposes continues to be mostly renegaded to individual chart review and/or manual entry in databanks. We hypothesized that standard EMR notes could be redesigned to provide customary documentation and allow automated clinical data retrieval by commercially available text data extraction software (TDES), with minimal disruption to provider workflow (documentation time). METHODS: Twenty fictitious patients undergoing reduction mammoplasty were created. Fictitious encounters included initial consultation, preoperative visit, operation, and postoperative visits at 1, 8, and 25 weeks. Each encounter was documented with our previous standard note (SN) and a redesigned “data-friendly” note (DFN). Documentation time was measured and compared between the 2 note groups. All DFNs were then exported in PDF format and fed into a TDES for data accrual. Seventy-six variables were assigned for monitoring and retrieval, spanning from patient demographics, to elements of the history and physical, to operative details, to clinical outcomes.
RESULTS: Model performance decreased with lengthening readmission intervals (Table). For example, 5-day readmissions performed better than 30-day readmissions on all statistical tests: 0.080 vs 0.052 (pseudoR2), 0.71 vs 0.66 (c-statistic), 0.54 vs 0.47 (next-year reliability).
RESULTS: The TDES successfully analyzed all 120 DFNs (300 pages) in less than 10 seconds, generating a database containing 4,850 clinical data points. Total documentation time per patient was found to be less in the DFN group (20.51.5 min) than in the SN group (21.3 1.6 min), reaching statistical significance (p<0.01).
Table. Model Performance and Reliability of Individual Readmission Measures
CONCLUSIONS: Redesigned “data-friendly” EMR notes allow automated clinical data retrieval by commercially available text data extraction software and decrease provider documentation time.
Logistic regression model performance
Year-to-year reliability* Readmissions % of 2005-07 2005-07 measure patients Pseudo-R2 c-statistic vs 2008 vs 2009
30-d 1-5 d 1-10 d 1-15 d 6-10 d 11-15 d 16-30 d
17.8 8.7 11.5 13.6 2.9 2.1 4.1
0.052 0.080 0.060 0.055 0.016 0.014 0.018
0.66 0.71 0.68 0.67 0.62 0.61 0.61
0.47 0.54 0.51 0.50 0.03 0.01 0.02
0.41 0.47 0.44 0.42 0.03 0.00 0.03
*The square of the coefficient of correlation between readmission rates assessed in each timeframe.
Safety-Net Burden Affects Cost and Outcomes at Academic Hospitals Richard S Hoehn, MD, Koffi Wima, Matthew A Vestal, MHA, Drew J Weilage, MHA, Daniel E Abbott, MD, FACS, Vishad Y Nabili, MD University of Cincinnati, Cincinnati, OH; Sg2 Health Care and Hospital System Consultancy, Chicago, IL; Centura Health, Denver, CO INTRODUCTION: Hospital safety-net burden is known to correlate with inferior patient outcomes. The aim of this study was to assess the influence of patient and hospital factors on these outcomes.
S132
J Am Coll Surg
Scientific Forum Abstracts
METHODS: Patients undergoing 9 major surgical procedures from 2009 to 2012 were queried using the University HealthSystem Consortium. Hospitals (n¼231) were grouped according to safety-net burden (proportion of Medicaid/uninsured charges for all 12,638,166 patient encounters). Surgical procedure patient cohorts were examined for preoperative characteristics, postoperative outcomes, and resource use. Gamma regression was used to analyze the effect of patient and center characteristics on surgical outcomes and costs. Medicare Hospital Compare data was used to characterize the groups of hospitals. RESULTS: For all procedures examined, patients at high safety-net burden hospitals (HBH) were most likely youngest, of black race, and had lowest socioeconomic status, highest severity of illness, and highest cost for surgical care. For most procedures, HBH also had the most emergent cases, longest length of stay, highest mortality, and highest readmissions. After adjusting for patient characteristics and hospital procedure-specific volume, HBH were still 6% to 26% more expensive than low safety-net burden hospitals (Table, all p<0.001). Analysis of Medicare data found HBH had worse performance on SCIP measures, more surgical complications, and inferior markers of emergency department timeliness and efficiency.
Procedure
Coronary artery bypass grafting Colectomy Esophagectomy Hip replacement Kidney transplant Knee replacement Pancreaticoduodenectomy Pulmonary lobectomy Ventral hernia repair
Risk ratio adjusted for Risk ratio patient adjusted for factors and Risk ratio patient hospital unadjusted factors volume
1.12 1.68 1.44 1.37 1.11 1.30 1.31 1.50 1.25
1.06 1.23 1.27 1.27 1.13 1.25 1.20 1.23 1.10
1.06 1.21 1.26 1.12 1.12 1.09 1.20 1.16 1.10
CONCLUSIONS: These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost. This is likely due to hospital resources, and impending changes to reimbursement may further affect the quality of surgical care at these centers. Sharps Injuries in the Operating Room Sterile Fields of an Academic Tertiary Care Center Naveen F Sangji, MD, MPH, Sandra Silvestri, RN, Evelyn Abayaah, David C Chang, PhD, MBA, MPH, Matthew M Hutter, MD, MPH, FACS, Catherine O’Malley, RN, MSN Massachusetts General Hospital, Boston, MA INTRODUCTION: Data on the prevalence and distribution of operating room (OR) sterile field sharps injuries sustained by
attending surgeons, residents, scrub nurses, and surgical (scrub) technologists are limited. We attempted to understand current sharps handling practices, injuries, and reporting behavior among the OR staff at our academic center to identify interventions that may improve sterile field sharps safety and reporting. METHODS: An electronic survey with questions pertaining to sharps handling practices, injuries, and reporting was emailed to 864 staff members between July and September 2014. Two reminders were sent. Adjusting for practice years and safety training, analysis for risk of injury was performed relative to attending surgeons. RESULTS: The overall response rate was 49% (n ¼426), with 368 completed surveys. Of the respondents, 163 (44%) reported a total of 434 injuries in the preceding 3 years. Attending surgeons and residents comprised 65% of injured staff and sustained 69% of the total injuries. Residents had a similar likelihood of injury (odds ratio [OR] 0.9, 95% CI, 0.37-2.2); scrub nurses (OR 0.3, 95% CI, 0.17-0.54) and technologists (OR 0.3, 95% CI, 0.140.76) had a lower likelihood. Half of those injured reported to Occupational Health Service (OHS). Scrub technologists were most likely to report (OR 15, 95% CI, 3.3-69.7). Of those who did not report, 46% stated time as a limiting factor. CONCLUSIONS: Attending surgeons and residents sustain the majority of sterile field sharps injuries and are the least likely to report them. Interventions include standardization of sharps handling, shorter safety reports, and an on-site OHS presence to expedite the reporting process. Significant Variation in Surgical Supply Cost Secondary to Surgeon Preference for Laparoscopic Cholecystectomy Michelle C Nguyen, MD, Matthew J Luzum, MD, David B Renton, MD, FACS, Gary S Phillips, Susan D Moffatt-Bruce, MD, PhD, FACS Ohio State University Wexner Medical Center, Columbus, OH INTRODUCTION: Variation in surgical supply use among surgeons can lead to unwarranted increased costs within operating rooms (OR). The aim of this study was to determine the surgical supply cost variation among surgeons performing laparoscopic cholecystectomies (LCs). METHODS: Surgical supply cost data were collected retrospectively from financial accounting, inclusive of all surgeons performing consecutive single procedure LCs from November 1, 2011 to February 1, 2015. Surgeons with fewer than 5 LCs within the study period were excluded. Use of trocars, scissors, clips, skin closure materials, drapes, hemostatic agents, suction irrigators, and specimen retrieval bags were selected for analysis. RESULTS: A total of 1,252 cases were performed by 20 surgeons. The surgical supply cost varied widely, from $346 to $2,829. The median supply cost was $818 (Figure). Patient age and sex did not affect the mean cost in a statistically significant way (p¼0.534 and 0.150, respectively). Variation between surgeon preference in supply use