Assessment of Magnet status and Textbook Outcomes among medicare beneficiaries undergoing hepato-pancreatic surgery for cancer.
The relationship between hospital Magnet status recognition and postoperative outcomes following complex cancer surgery remains ill-defined. We sought to characterize Textbook Outcome (TO) rates among patients undergoing (HP) surgery for cancer in Magnet versus non-Magnet centers.
Medicare beneficiaries undergoing HP surgery between 2015 and 2017 were identified. The association of postoperative TO (no complications/extended length-of-stay/90-day mortality/90-day readmission) with Magnet designation was examined after adjusting for competing risk factors.
Among 10,997 patients, 21.3% (n = 2337) patients underwent surgery at Magnet hospitals (non-Magnet centers: 78.7%, n = 8660). On multivariable analysis, patients undergoing HP surgery had comparable odds of achieving a TO at Magnet versus non-Magnet hospitals (hepatectomy: odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.94-1.17; pancreatectomy-OR: 0.88, 95% CI: 0.74-1.06). Patients treated at hospitals with a high nurse-to-bed ratio had higher odds of achieving a TO irrespective of whether they received surgery at Magnet (high vs. low nurse-to-bed ratio; OR: 1.38; 95% CI: 1.01-1.89) or non-Magnet centers (OR: 1.26; 95% CI: 1.10-1.45). Similarly, hospital HP volume was strongly associated with higher odds of TO following HP surgery in both Magnet (Leapfrog compliant vs. noncompliant; OR: 1.24, 95% CI: 1.06-1.44) and non-Magnet centers (OR: 1.18; 95% CI: 1.11-1.26).
Hospital Magnet designation was not an independent factor of superior outcomes after HP surgery. Rather, hospital-level factors such as nurse-to-bed ratio and HP procedural volume drove outcomes.
Mehta R
，Tsilimigras DI
，Pawlik TM
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Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer.
We sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer.
Standard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition.
Among 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76-0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82-0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06-1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10-1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21-1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90-1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98-1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes.
Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.
Mehta R
，Tsilimigras DI
，Paredes A
，Dillhoff M
，Cloyd JM
，Ejaz A
，Tsung A
，Pawlik TM
... -
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Association of social vulnerability with the use of high-volume and Magnet recognition hospitals for hepatopancreatic cancer surgery.
In an effort to improve perioperative and oncologic outcomes, there have been multiple quality improvement initiatives, including regionalization of high-risk procedures and hospital accreditation designations from independent organizations. These initiatives may, however, hinder access to high-quality surgical care for certain patients living in areas with high social vulnerability who may be disproportionally affected, leading to disparities in access and worse postoperative outcomes.
Medicare beneficiaries who underwent liver or pancreas resection for cancer were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals were designated as high-volume based on Leapfrog criteria. The Centers for Disease Control and Prevention's social vulnerability index database was used to abstract social vulnerability index information based on each beneficiary's county of residence at the time of operation. The probability that a patient received care at a high-volume hospital stratified by the social vulnerability of the patient's county of residence was examined. Risk-adjusted postoperative outcomes were compared across low, average, and high levels of vulnerability at both low- and high-volume hospitals.
Among 16,978 Medicare beneficiaries who underwent a pancreatectomy (n = 13,393, 78%) or a liver resection (n = 3,594, 21.2%) for cancer, the mean age was 73.3 years (standard deviation: 5.8), nearly half the cohort was female (n = 7,819, 46%), and the overwhelming majority were White (n = 15,034, 88.5%). Mean social vulnerability index was 49.8 (standard deviation 24.8) and mean Charlson comorbidity index was 4.8 (standard deviation: 3). Overall, 8,251 (48.6%) of patients had their operations at a high-volume hospital, and 3,802 patients had their operations at a hospital with Magnet recognition. Age and sex were similar within the low-, average-, and high-social vulnerability index cohorts (P > .05); however, race differed across social vulnerability index groups. White patients made up 93% (n = 3,241) of the low social vulnerability index compared with 83.9% (n = 2,706) of the high-social vulnerability index group, whereas non-Whites made up 7% (n = 244) of the low-social vulnerability index group compared with 16.1% (n = 556) of the high-social vulnerability index group (P < .001). The risk-adjusted overall probability of having surgery at a high-volume hospital decreased as social vulnerability increased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Risk-adjusted probability of postoperative complications increased with social vulnerability index; however, among patients with high social vulnerability, risk of postoperative complications was lower at high-volume hospitals compared with low-volume hospitals. In contrast, there was no difference in postoperative complications between hospitals with and without Magnet recognition across social vulnerability index.
Patients residing in communities characterized by a high social vulnerability index were less likely to undergo high-risk cancer surgery at a high-volume hospital. Although postoperative complications and mortality increased as social vulnerability index increased, some of the risk appeared to be mitigated by having surgery at a high-volume hospital. These data highlight the importance of access to high-quality surgical care, especially among patients who may already be more vulnerable.
Diaz A
，Hyer JM
，Azap R
，Tsilimigras D
，Pawlik TM
... -
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