Does Hospital Experience Rather than Volume Improve Outcomes in Geriatric Trauma Patients?

Although high absolute hospital geriatric trauma volume (GTV) is associated with improved outcomes among geriatric trauma patients, the actual geriatric trauma proportion (GTP) might be a better predictor of outcomes. Adult trauma admissions were identified in the California State Inpatient Database, 2007 to 2011. Hospital characteristics were extracted from the American Hospital Association database. The annual trauma volume of patients 65 years and older was calculated for each hospital. The GTP was derived by dividing the GTV by the overall adult trauma volume and hospitals were categorized into tertiles of GTP. Outcomes were hospital mortality, failure to rescue (FTR), and 30-day readmission in geriatric trauma patients. Independent risk factors were assessed with clustered multivariate logistic regression models adjusted for patient and hospital characteristics. There were 61,915 geriatric trauma patients included from 63 trauma centers. Hospital mortality, FTR, and 30-day readmission rates were 4.99%, 16.07%, and 12.03%, respectively. The adjusted odds ratios and 95% CIs for in-hospital mortality and FTR per 100 patient increase in GTV were 0.91 (95% CI, 0.83-1.00) and 1.01 (95% CI, 0.90-1.14), respectively. As compared with hospitals in the lowest tertile, adjusted odds of mortality and FTR in the highest tertile were 0.71 (95% CI, 0.54-0.94) and 0.67 (95% CI, 0.48-0.92), respectively. None of the hospital factors measured was significantly associated with readmission. The Wald test revealed that GTP played a larger role than GTV in predicting hospital mortality (p = 0.018 vs p = 0.048) and FTR (p = 0.015 vs p = 0.985). Treatment at hospitals with higher GTP is associated with lower hospital mortality and FTR among geriatric patients. These findings suggest that creation of specialized services for geriatric trauma care can improve outcomes among geriatric trauma patients.

Olufajo OA ，Metcalfe D ，Rios-Diaz A ，Lilley E ，Havens JM ，Kelly E ，Weissman JS ，Haider AH ，Salim A ，Cooper Z ... -  《-》

The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer.

Although previous reports have focused on factors at the hospital level to explain variations in postoperative outcomes, less is known regarding the effect of provider-specific factors on postoperative outcomes such as failure-to-rescue (FTR) and postoperative mortality. The current study aimed to quantify the relative contributions of surgeon and hospital volume on the volume-outcomes relationship among a cohort of patients undergoing liver resection. Patients undergoing liver surgery for cancer were identified using the Nationwide Inpatient Sample from 2001 and 2009. Multivariable logistic regression analysis was performed to identify factors associated with mortality and FTR. Point estimates were used to calculate the relative effects of hospital and surgeon volume on mortality and FTR. A total of 5,075 patients underwent liver surgery and met inclusion criteria. Median patient age was 62 years (interquartile range, 52-70) and 55.2% of patients were male. Mortality was lowest among patients treated at high-volume hospitals and among patients treated by high-volume surgeons (both P < .001). Similar patterns in FTR were noted relative to hospital and surgeon volume (hospital volume: low vs intermediate vs high; 10.3 vs 9.0 vs 5.2%; surgeon volume: low vs intermediate vs high, 11.1 vs 9.1 vs 4.1%; both P < .05). On multivariable analysis, compared with high-volume surgeons, lower volume surgeons demonstrated greater odds for mortality (intermediate: odds ratio [OR], 2.27 [95% CI, 1.27-4.06; P = .006]; low, OR, 2.83 [95% CI, 1.52-5.27; P = .001]), and FTR (intermediate: OR, 2.86 [95% CI, 1.53-5.34, P = .001]; low, OR, 3.40 [95% CI, 1.75-6.63; P < .001]). While hospital volume accounted for 0.5% of the surgeon volume effect on increased FTR for low-volume surgeons, surgeon volume accounted for nearly all of the hospital volume effect on increased FTR in low-volume hospitals. The risk of complications, mortality, and FTR were less among both high-volume hospitals and high-volume surgeons, but the beneficial effect of volume on outcomes was attributable largely to surgeon volume.

Buettner S ，Gani F ，Amini N ，Spolverato G ，Kim Y ，Kilic A ，Wagner D ，Pawlik TM ... -  《-》

Positive and negative volume-outcome relationships in the geriatric trauma population.

Matsushima K ，Schaefer EW ，Won EJ ，Armen SB ，Indeck MC ，Soybel DI ... -  《-》

Impact of hospital volume on patient safety indicators and failure to rescue following open aortic aneurysm repair.

Failure to rescue (FTR), a patient safety indicator (PSI) defined, codified, and adjudicated by the Agency for Healthcare Research and Quality, is classified as a preventable inpatient death following major complications. FTR has been reported to be a significant driver of postoperative mortality after open abdominal aortic aneurysm (OAAA) repair. The association between hospital volume (HV) and mortality is well known; however, the mechanisms responsible for these improved outcomes and relative contribution to observed interhospital variation is poorly understood. Similarly, HV influence on specific complications predictive of FTR is unknown; therefore, we sought to determine how HV influences risk and contributes to interhospital variation in PSI events leading to FTR and/or in-hospital mortality after OAAA repair. The Vizient database (174 academic/nonacademic hospitals) was queried for all OAAA repairs (elective, n = 2827; nonelective, n = 1622) completed from 2012 to 2014. The primary endpoint was combined FTR and/or in-hospital 30-day mortality. Risk-adjusted rates of complications, Agency for Healthcare Research and Quality-designated PSIs, and FTR were determined. Additional modeling identified PSIs associated with FTR, whereas HV effects on PSIs and FTR were evaluated using mixed-effect models accounting for interhospital variation. Proportion of variation attributable to HV was estimated by contrasting hospital random effect variances in the presence/absence of volume effects. The combined overall FTR/in-hospital 30-day mortality rate was 9.3% (n = 414). For elective and nonelective cases, the overall FTR and 30-day mortality rates were: FTR, 1.6%, 4.9%; and 30-day in-hospital mortality, 3.4%, 17.5%, respectively. HV significantly influenced FTR/30-day in-hospital mortality (P < .0001). FTR/30-day mortality odds for hospitals with 3-year volumes of 50, 100, 150, and 200 cases were 1.4, 2.0, 2.7, and 3.0 times lower, respectively, than hospitals performing ≤25 cases/3 years. The proportion of interhospital variation attributed to HV was greatest for FTR/30-day mortality (62%). Procedural volume accounted for 41% and 38% of interhospital variation in postoperative bleeding and myocardial infarction, respectively. Preoperative predictors of FTR included coagulopathy, arrhythmia (nonelective cases); congestive heart failure, obesity (elective cases); and age, neurological disease, hypertension, and valvular disease (all cases). OAAA FTR/30-day in-hospital mortality strongly correlated with annual case volume with higher volume centers having the lowest risk. Notably, HV accounted for a significant proportion of the observed variation in FTR and specific complications providing direct evidence for how the volume-outcome relationship may influence perioperative mortality. These findings can inform stakeholders to strategically enable them to implement processes of care directed at the most vulnerable patients that are designed to reduce the likelihood of preventable adverse events and death after OAAA repair. Furthermore, these results underscore the need to regionalize OAAA repair and potentially other complex operations, to HV centers because of their improved ability to rescue patients experiencing complications associated with postoperative mortality.

Scali ST ，Giles KA ，Kubilis P ，Beck AW ，Crippen CJ ，Hughes SJ ，Huber TS ，Upchurch GR Jr ，Stone DH ... -  《-》

Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery.

Failure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR. The Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals). A total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897). After adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery.

Rosero EB ，Joshi GP ，Minhajuddin A ，Timaran CH ，Modrall JG ... -  《-》