Publications by authors named "Andrew Ibrahim"

48 Publications

The ACA at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

J Surg Res 2021 Feb 25;263:102-109. Epub 2021 Feb 25.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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http://dx.doi.org/10.1016/j.jss.2020.12.056DOI Listing
February 2021

Evaluation of US Hospital Episode Spending for Acute Inpatient Conditions After the Patient Protection and Affordable Care Act.

JAMA Netw Open 2020 11 2;3(11):e2023926. Epub 2020 Nov 2.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts.

Objective: To evaluate the association between the enactment of ACA reforms and 30-day price-standardized hospital episode spending.

Design, Setting, And Participants: This policy evaluation included index discharges between January 1, 2008, and August 31, 2015, from a national random 20% sample of Medicare beneficiaries. Data analysis was performed from February 1, 2019 to July 8, 2020.

Exposure: Payment reforms after passage of the ACA.

Main Outcomes And Measures: 30-day price-standardized episode payments. Three alternative estimation approaches were used to evaluate the association between reforms following the ACA and episode spending: (1) a difference-in-difference (DID) analysis among acute care hospitals, comparing spending for diagnoses commonly targeted by ACA programs with nontargeted diagnoses; (2) a DID analysis comparing acute care hospitals and critical access hospitals (not exposed to reforms); and (3) a generalized synthetic control analysis, comparing acute care and critical access hospitals. Supplemental analysis examined the degree to which Medicare fee cuts contributed to spending reductions.

Results: A total of 7 634 242 index discharges (4 525 630 [59.2%] female patients; mean [SD] age, 79.31 [8.02] years) were included. All 3 approaches found that reforms following the ACA were associated with a significant reduction in episode spending. The DID estimate comparing targeted and untargeted diagnoses suggested that reforms following the ACA were associated with a -$431 (95% CI, -$492 to -$369; -2.87%) change in total spending, while the generalized synthetic control analysis suggested that reforms were associated with a -$1232 (95% CI, -$1488 to -$965; -10.12%) change in total episode spending, amounting in a total annual savings of $5.68 billion. Cuts to Medicare fees accounted for most of these savings.

Conclusions And Relevance: In this policy evaluation, the ACA was associated with large reductions in US hospital episode spending.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.23926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684450PMC
November 2020

Impact Of Medicare Readmissions Penalties On Targeted Surgical Conditions.

Health Aff (Millwood) 2019 07;38(7):1207-1215

Justin B. Dimick is the Frederick A. Coller Professor and Chair of the Department of Surgery, University of Michigan.

The Hospital Readmissions Reduction Program, announced in 2010 to penalize excess readmissions for patients with selected medical diagnoses, was expanded in 2013 to include targeted surgical diagnoses, beginning with hip and knee replacements. Whether these surgical penalties reduced procedure-specific readmissions is not well understood. Using Medicare claims, we evaluated the penalty announcements' effects on risk-adjusted readmission rates, episode payments, lengths-of-stay, and observation status use. Risk-adjusted readmission rates declined for both procedures from 7.6 percent in 2008 to 5.5 percent in 2016. These rates were decreasing before the program was announced, but the rate of reductions doubled after the announcement of medical penalties in March 2010 (from -0.05 percentage points to -0.10 percentage points per quarter). After targeted surgical penalties were announced in August 2013, readmission reductions returned to near the baseline trend. During the same time period, mean episode payments and lengths-of-stay decreased substantially, and trends in observation status were unchanged. This suggests that medical readmission penalties led to readmission reductions for surgical patients as well, that targeted surgical penalties did not have an additional effect, and that readmission reductions are approaching a "floor" below which further reductions may be unlikely.
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http://dx.doi.org/10.1377/hlthaff.2019.00096DOI Listing
July 2019

A Decade Later, Lessons Learned From the Hospital Readmissions Reduction Program.

JAMA Netw Open 2019 05 3;2(5):e194594. Epub 2019 May 3.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamanetworkopen.2019.4594DOI Listing
May 2019

Improving the Delivery of Surgical Care Within Regional Hospital Networks.

Ann Surg 2019 06;269(6):1016-1017

Department of Surgery and the Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

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http://dx.doi.org/10.1097/SLA.0000000000003182DOI Listing
June 2019

Improving the Delivery of Common Medical Procedures to Achieve Value-Based Care.

JAMA Intern Med 2019 07;179(7):963-964

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamainternmed.2019.0001DOI Listing
July 2019

Variation in Surgical Outcomes Across Networks of the Highest-Rated US Hospitals.

JAMA Surg 2019 06;154(6):510-515

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Hospitals are rapidly consolidating into regional delivery networks. To our knowledge, whether these multihospital networks leverage their combined assets to improve quality and provide a uniform standard of care has not been explored.

Objective: To evaluate the extent to which surgical outcomes varied across hospitals within the networks of the highest-rated US hospitals.

Design, Settings, And Participants: This longitudinal analysis of 87 hospitals that participated in 1 of 16 networks that are affiliated with US News & World Report Honor Roll hospitals used data from Medicare beneficiaries who were undergoing colectomy, coronary artery bypass graft, or hip replacement between 2005 and 2014 to evaluate the variation in risk-adjusted surgical outcomes at Honor Roll and affiliated hospitals within and across networks. The data were analyzed between April 20, 2018, and June 25, 2018.

Main Outcomes And Measures: Thirty-day postoperative complications, mortality, failure to rescue, and readmissions.

Results: Of 143 174 patients, 68 718 (48.0%) were men, 124 427 (86.9%) were white, and the mean (SD) age was 71.8 (9.9) years and 73.5 (9.1) years in Honor Roll and affiliated hospitals, respectively. Outcomes were not consistently better at Honor Roll hospitals compared with network affiliates. For example, Honor Roll hospitals had lower failure to rescue rates (13.3% vs 15.1%; odds ratio, 0.92; 95% CI, 0.86-0.98) but higher complication rates (22.1% vs 18.0%; odds ratio, 1.11; 95% CI, 1.03-1.19). Within networks, risk-adjusted outcomes varied widely across affiliated hospitals. The differences in failure to rescue varied by as little as 1.1-fold (range, 12.7%-14.3%) in some networks to as much as 4.9-fold (range, 7.6%-37.3%) in others. Similarly, complication rates varied by 1.1-fold (range, 21%-23%) to 4.3-fold (range, 6%-26%) across all networks.

Conclusions And Relevance: Surgical outcomes vary widely across hospitals affiliated with the US News & World Report Honor Roll hospitals. Public reporting mechanisms should provide patients with information on the quality of all network-affiliated hospitals. Networks should monitor variations in outcomes to characterize and improve the extent to which a uniform standard of care is being delivered.
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http://dx.doi.org/10.1001/jamasurg.2019.0090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583390PMC
June 2019

Measuring and Improving the Design Quality of Operating Rooms.

Surg Infect (Larchmt) 2019 Feb/Mar;20(2):102-106

2 HOK Architects, St. Louis, Missouri.

Background: Existing research regarding design improvements to the operating room (OR) is scarce and emphasizes the compelling need to measure and test new design strategies and interventions.

Methods: We propose a conceptual framework for measuring and improving OR physical space design by outlining how two existing measurement schemes can be adapted for ORs. The structure, process, outcomes model described by Donabedian in 1966 is used to show how each of these three measurement approaches can be used to evaluate OR design. In addition, we describe a common design framework that focuses on the end-user experience to highlight the impact different OR stakeholders can have on the prioritization of improvements.

Results: The structure, process, outcomes model has both benefits and drawbacks for measuring OR design quality. For example, these components are easy to measure, highly actionable when deficient, and have high validity as the bottom line. However, they may not necessarily reflect better quality or correlate to better care, and some need risk adjustment to make comparisons fair. The end-user experience model should account for the needs of patients, OR nurses, anesthesiologists, surgeons, facilities managers, hospital administrators, infection control officers, and regulators, among others.

Conclusion: The design quality of ORs influences outcomes and determines the quality of experience for multiple stakeholders. Patients, providers, and hospital staff would benefit directly from efforts to improve OR physical space design. By adapting previously established frameworks, it is possible to measure, evaluate, and improve OR design.
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http://dx.doi.org/10.1089/sur.2018.291DOI Listing
March 2019

Understanding the psychosocial impact of weight loss following bariatric surgery: a qualitative study.

BMC Obes 2018 3;5:38. Epub 2018 Dec 3.

3Department of Surgery, University of Michigan, Ann Arbor, MI USA.

Background: Bariatric surgery leads to changes in mental health, quality of life and social functioning, yet these outcomes differ among individuals. In this study, we explore patients' psychosocial experiences following bariatric surgery and elucidate the individual-level factors that may drive variation in psychosocial outcomes.

Methods: Eleven semi-structured focus groups with Michigan Bariatric Surgery Collaborative (MBSC) patients ( = 77). Interviews were audio recorded, transcribed verbatim, and analyzed using a grounded theory approach. Data on participant demographic characteristics were abstracted from the MBSC clinical registry.

Results: Most focus group participants were female (89%), white (64%), and married (65%). We identified three major themes: (1) change in self-perception; (2) change in perception by others; and (3) change in relationships. Each theme includes 3 sub-themes, demonstrating a range of positive and negative psychosocial experiences. For example, weight loss led to increased self-confidence among many participants while others described a loss of self-identity. Some noted improved relationships with family or friends while others experienced worsening or even loss of relationships due to perceived jealousy.

Conclusion: Weight loss following bariatric surgery leads to complex changes in self-perception and inter-personal relationships, which may be proximal mediators of commonly assessed mental health outcomes such as depression. Individuals considering bariatric surgery may benefit from anticipatory guidance about these diverse experiences, and post-surgical longitudinal monitoring should include evaluation for adverse psychosocial events.
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http://dx.doi.org/10.1186/s40608-018-0215-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276134PMC
December 2018

Sprint to work: A novel model for team science collaboration in academic medicine.

Perspect Med Educ 2018 08;7(4):281-285

Center for Evaluating Health Reform, School of Public Health, University of Michigan, Ann Arbor, MI, USA.

Collaborative research in academic medicine is often inefficient and ineffective. It often fails to leverage the expertise of interdisciplinary team members, does not seek or incorporate team input at opportune times, and creates workload inequities. Adapting approaches developed in venture capital, we created the 'sprint model' for writing academic papers based on the analysis of secondary data. The 'sprint model' minimizes common barriers that undermine collaboration in academic medicine. This model for team science collaboration begins with team members convening for a highly focused, guided session. In this session, a facilitator moves the group through a structured process to create the study plan. This includes refining the research questions, developing the study design, and prototyping the presentation of results. After adopting this model, our team has drastically reduced time from idea inception to final product submission through increased efficiencies and reduced redundancies. From December 2016 to April 2018, our team has initiated 15 paper sprints. The median time from sprint to submission for paper sprints has been 1.7 months (minimum: 0.5; maximum: 9). Although our current 'sprint' approach has already demonstrated a substantial improvement in our ability to rapidly produce high-quality research, we believe the 'pre-sprint' preparation and 'post-sprint' processes can be further refined. Finally, we discuss the limitations of this model and our efforts to adapt the process to meet the evolving needs of research teams.
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http://dx.doi.org/10.1007/s40037-018-0442-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086814PMC
August 2018

Association of Hospital Network Participation With Surgical Outcomes and Medicare Expenditures.

Ann Surg 2019 08;270(2):288-294

Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.

Objective: The aim of this study was to evaluate whether hospital network participation is associated with improvement in surgical outcomes and spending compared to control hospitals not participating in a network.

Summary Background Date: Hospitals face significant financial and organizational pressures to integrate into networks. It remains unclear whether these business arrangements impact clinical quality or healthcare expenditures.

Methods: We conducted a longitudinal, quasi-experimental study of 1,981,095 national Medicare beneficiaries (2007-2014) undergoing general, vascular, cardiac, or orthopedic surgery at a network (n = 1868) or non-network (n = 2734) hospital. We tested whether joining a network was associated with improvement in the study outcomes after accounting for overall trends toward better outcomes. We used hierarchical multivariable logistical and linear regression to adjust for patient factors, procedural characteristics, type of admission, and hospital factors.

Results: After accounting for patient factors and existing trends toward better outcomes, there was no association between network participation and surgical outcomes. For example, the rates of serious complications were similar between network [11.4%, 95% confidence interval (CI) 11.1%-11.5%] and non-network hospitals (11.2%; 95% CI 11.0%-11.3%; odds ratio 1.00, 95% CI 0.97-1.03, P = 0.92). There was no association between time-in-network and improvement in rates of serious complications during the 8-year study period. For example, after 7 years of network participation, the rate of serious complications in 2014 was 9.6% (95% CI 8.8%-10.4%) in network hospitals versus 9.2% (95% CI 8.5%-9.9%, P = 0.11) in non-network hospitals.

Conclusions: Hospital network participation was not associated with improvements in patient outcomes or lower episode payments among Medicare beneficiaries undergoing inpatient surgery.
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http://dx.doi.org/10.1097/SLA.0000000000002791DOI Listing
August 2019

What Metrics Accurately Reflect Surgical Quality?

Annu Rev Med 2018 01;69:481-491

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48105; email:

Surgeons are increasingly under pressure to measure and improve their quality. While there is broad consensus that we ought to track surgical quality, there is far less agreement about which metrics matter most. This article reviews the important statistical concepts of case mix and chance as they apply to understanding the observed wide variation in surgical quality. We then discuss the benefits and drawbacks of current measurement strategies through the framework of structure, process, and outcomes approaches. Finally, we describe emerging new metrics, such as video evaluation and network optimization, that are likely to take on an increasingly important role in the future of measuring surgical quality.
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http://dx.doi.org/10.1146/annurev-med-060116-022805DOI Listing
January 2018

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Accreditation-Reply.

JAMA Surg 2018 02;153(2):191-192

Department of Surgery, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2017.4590DOI Listing
February 2018

Outcomes After Adjustable Gastric Banding-Reply.

JAMA Surg 2018 02;153(2):190-191

Department of Surgery, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2017.4514DOI Listing
February 2018

Educational content and the use of social media at US departments of surgery.

Surgery 2018 02 11;163(2):467-471. Epub 2017 Dec 11.

University of Michigan, Department of Surgery. Ann Arbor, MI.

Background: The growth of the social media platform Twitter has prompted many to consider its potential as an educational tool. Little is known about how surgery training programs are utilizing this resource and whether this platform can provide educational content effectively. We sought to determine national utilization of Twitter by departments of surgery in the United States and evaluate if educationally driven content heightened engagement with the Twitter followers.

Methods: We conducted a cross-sectional analysis of social media presence for all Accreditation Council for Graduation Medical Education accredited general surgery training programs between October 1, 2016 and December 31, 2016. Each tweet was characterized as either promotional or educational. Metrics related to account engagement, including impressions (number of times a tweet is seen) and retweets (number of times a tweet is shared), were compared. These results were compared against a single departmental account focused primarily on educational content.

Results: Thirty-two departmental Twitter accounts were identified from the 272 programs approached associated with accredited general surgery training programs. Training programs posted a median of 1.0 unique tweets (interquartile range: 0.6-2.3) per week. Tweets were primarily promotional (81% of posts) and generated marginal engagement with followers (3.4 likes/tweet; 1.5 retweets/tweet). In contrast, a single, resident-run departmental account at our institution (University of Michigan) focused on educational content generated consistent, educational content (19.6 unique tweets/week, 48% of which were educational), which resulted in increased engagement with followers (11.4 likes/tweet; 5.9 retweets/tweet) compared to other accounts.

Conclusion: Though Twitter is being widely adopted widely by departments of surgery, it is primarily utilized for promotional content. Use of educational content may improve engagement from followers.
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http://dx.doi.org/10.1016/j.surg.2017.10.039DOI Listing
February 2018

Pretherapy neutrophil to lymphocyte ratio and platelet to lymphocyte ratio do not predict survival in resectable pancreatic cancer.

HPB (Oxford) 2018 05 6;20(5):398-404. Epub 2017 Dec 6.

Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland OH, USA. Electronic address:

Background: Pretherapy serum neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) have both been identified as prognostic in pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to identify the prognostic implication of pretherapy NLR and PLR in patients with resectable PDAC.

Methods: Data were collected retrospectively on patients operated at our institution between 2004 and 2014. A Cox proportional hazards model was used to investigate the relationship between clinical and pathological parameters, NLR and PLR to overall survival (OS). Survival data were analyzed using the Kaplan-Meier method.

Results: 217 patients were analyzed with a median overall survival (OS) of 17.5 months. Factors identified as being predictive of OS by univariate analysis included age, receipt of adjuvant therapy, margin positivity, pathologic angiolymphatic invasion, T-stage, and N-stage (P < 0.05). Factors identified as being independently predictive of OS by multivariate analysis included age and angiolymphatic invasion (P < 0.05). NLR and PLR were not predictive of OS. Survival analysis demonstrated no difference in OS in patients who had high or low NLR or PLR.

Discussion: Pretherapy NLR and PLR do not predict survival in patients who underwent pancreatectomy for PDAC at our institution.
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http://dx.doi.org/10.1016/j.hpb.2017.10.011DOI Listing
May 2018

Medical Device Identification in Claims Data-Reply.

JAMA 2017 11;318(19):1937

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jama.2017.15161DOI Listing
November 2017

Seeing is Believing: Using Visual Abstracts to Disseminate Scientific Research.

Authors:
Andrew M Ibrahim

Am J Gastroenterol 2018 04 19;113(4):459-461. Epub 2017 Sep 19.

Institute for Healthcare Policy & Innovation, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1038/ajg.2017.268DOI Listing
April 2018

What Does the Future Hold for Scientific Journals? Visual Abstracts and Other Tools for Communicating Research.

Clin Colon Rectal Surg 2017 Sep 12;30(4):252-258. Epub 2017 Sep 12.

Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Journals fill several important roles within academic medicine, including building knowledge, validating quality of methods, and communicating research. This section provides an overview of these roles and highlights innovative approaches journals have taken to enhance dissemination of research. As journals move away from print formats and embrace web-based content, design-centered thinking will allow for engagement of a larger audience. Examples of recent efforts in this realm are provided, as well as simplified strategies for developing visual abstracts to improve dissemination via social media. Finally, we hone in on principles of learning and education which have driven these advances in multimedia-based communication in scientific research.
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http://dx.doi.org/10.1055/s-0037-1604253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5595539PMC
September 2017

Impact of the Hospital Readmission Reduction Program on Surgical Readmissions Among Medicare Beneficiaries.

Ann Surg 2017 10;266(4):617-624

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Objective: To understand the impact of the Hospital Readmission Reduction Program on both future targeted and nontargeted surgical procedures.

Background: The Hospital Readmission Reduction Program, established under the Affordable Care Act in March of 2010, placed financial penalties on hospitals with higher than expected rates of readmission beginning in 2012 for targeted medical conditions. Multiple studies have suggested a "spill-over" effect into other conditions, but the extent of that effect for specific surgical procedures is unknown.

Methods: A retrospective review 5,122,240 Medicare beneficiaries who underwent future targeted procedures (total hip replacement, total knee replacements) or nontargeted procedures (colectomy, lung resection, abdominal aortic aneurysm repair, coronary artery bypass graft, aortic valve replacement, mitral valve repair) using an interrupted time series model to assess the rates of readmission before the Hospital Readmission Reduction Program was announced (2008-2010), whereas the program was being implemented (2010-2012) and after penalties were initiated (2012-2014). We also explored if the change in readmission rates were correlated with changes in index length of stay, use of observation status, or discharge to a skilled nursing facility.

Results: From 2008 to 2014 rates of readmission declined for both target conditions (6.8%-4.8%; slope change -0.07 to -0.10, P < 0.001) and nontarget conditions (17.1%-13.4%; slope change -0.04 to -0.11, P < 0.001). The rate of reduction was most prominent after announcement of the program between 2010 and 2012 for both targeted and nontargeted conditions. During the same time period, mean hospital length of stay decreased; nontargeted conditions (10.4-8.4 days) and targeted conditions (3.6-2.8 days). There was no correlation between hospital reduction in readmissions and use of observation-only admissions (Pearson correlation coefficient = 0.01) or discharge to a skilled nursing facility (Pearson correlation coefficient = 0.05).

Conclusions: Trends in readmissions after inpatient surgery are consistent with hospitals responding to financial incentives announced in the Hospital Readmission Reduction Program. There appears to be both an anticipatory effect (future targeted procedures reducing readmission before payments implemented) and a spillover effect (nontargeted procedures also reducing readmissions).
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http://dx.doi.org/10.1097/SLA.0000000000002368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968452PMC
October 2017

Monitoring Medical Devices: Missed Warning Signs Within Existing Data.

JAMA 2017 07;318(4):327-328

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jama.2017.6584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118856PMC
July 2017

Toward Patient-Centered Hospital Design: What Can Airports Teach Us?

Ann Intern Med 2017 07 30;167(1):48-49. Epub 2017 May 30.

From Michigan Medicine and Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, and American Institute of Architects, Washington DC.

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http://dx.doi.org/10.7326/M17-0484DOI Listing
July 2017

Surgeon Experience and Medicare Expenditures for Laparoscopic Compared to Open Colectomy.

Ann Surg 2018 12;268(6):1036-1042

Department of Surgery, University of Michigan.

Objective: To quantify the extent to which payments for laparoscopic and open colectomy are influenced by a surgeon's experience with laparoscopy.

Background: Numerous studies suggest that healthcare costs for laparoscopic colectomy are lower than open surgery. None have assessed the importance of surgeon experience on the relative financial benefits of laparoscopy.

Methods: We conducted a study of 182,852 national Medicare beneficiaries undergoing laparoscopic or open colectomy between 2010 and 2012. Using instrumental variable methods to account for selection bias, we compared Medicare payments for laparoscopic and open colectomy. We stratified our analysis by surgeons' annual experience with laparoscopic colectomy to determine the influence of provider experience on payments.

Results: In the fully adjusted analysis, average episode payments per patient were $2640 [95% confidence interval (CI) -$4091 to -$1189] lower with the laparoscopic approach versus open. Surgeons in the highest quartile of laparoscopic experience demonstrated an average payment savings of $5456 per patient (CI -$7918 to -$2994) in their laparoscopic versus open cases. Among surgeons in the lowest quartile of laparoscopic experience, there was, however, no difference between laparoscopic and open cases (difference: $954, 95% CI -$731 to $2639). Differences in payments were explained by differences in complications rates. Both groups had similar rates of complications for open procedures (least experience, 21%, most experience, 21%; P = 0.45), but differed significantly on rates of complications for laparoscopic cases (least experience, 28%, most experience, 15%; P < 0.01).

Conclusions: This population-based study demonstrates that differences in payments between laparoscopic and open colectomy are influenced by surgeon experience. The laparoscopic approach does not reduce payments for patients whose surgeons have limited experience with the procedure.
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http://dx.doi.org/10.1097/SLA.0000000000002312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791353PMC
December 2018

Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery.

JAMA Surg 2017 Sep;152(9):835-842

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.

Importance: Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known.

Objective: To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort.

Design, Settings, And Participants: This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed.

Main Outcomes And Measures: Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations.

Results: Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device.

Conclusions And Relevance: Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.
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http://dx.doi.org/10.1001/jamasurg.2017.1093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710463PMC
September 2017

Visual Abstracts to Disseminate Research on Social Media: A Prospective, Case-control Crossover Study.

Ann Surg 2017 Dec;266(6):e46-e48

*Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI †Department of Surgery, Massachusetts General Hospital, Boston, MA ‡Department of Surgery, Washington University School of Medicine, St. Louis, MO.

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http://dx.doi.org/10.1097/SLA.0000000000002277DOI Listing
December 2017

Variation in Outcomes at Bariatric Surgery Centers of Excellence.

JAMA Surg 2017 07;152(7):629-636

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Surgical Innovation Editor, JAMA Surgery.

Importance: In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown.

Objective: To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers.

Design, Setting, And Participants: This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project's State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017.

Main Outcomes And Measures: Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume.

Results: In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation).

Conclusions And Relevance: Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.
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http://dx.doi.org/10.1001/jamasurg.2017.0542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831459PMC
July 2017

Site-specific Approach to Reducing Emergency Department Visits Following Surgery.

Ann Surg 2018 04;267(4):721-726

Department of Surgery, University of Michigan, Ann Arbor, MI.

Objective: The aim of this study was to explore the efficacy of current bariatric perioperative measures at reducing emergency department (ED) visits following bariatric surgery in the state of Michigan.

Summary Of Background Data: Many ED visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits.

Methods: We studied 48,035 eligible bariatric surgery patients across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk- and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery, and hospital summary characteristics were compared. We then studied whether a hospital's compliance with specific perioperative measures was significantly associated with reduced ED visit rates.

Results: Only 3 of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital's ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of venous thromboembolism complications (P = 0.04, P = 0.0065, and P = 0.0047, respectively). Also, a hospital's compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (P = 0.12).

Conclusions: Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.
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http://dx.doi.org/10.1097/SLA.0000000000002226DOI Listing
April 2018

Adoption of Visual Abstracts at : Why and How We're Doing It.

Circ Cardiovasc Qual Outcomes 2017 03;10(3)

From the Department of Surgery and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (A.M.I.); and Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (S.M.B.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.117.003684DOI Listing
March 2017

Emergency Surgery for Medicare Beneficiaries Admitted to Critical Access Hospitals.

Ann Surg 2018 03;267(3):473-477

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Objective: The aim of this study was to compare the surgical outcomes of emergency operations performed at critical access and non-critical access hospitals.

Background: Critical access hospitals are often the only source of surgical care for rural populations. Previous studies have demonstrated that patients undergoing common, elective operations at these rural hospitals have similar outcomes to their urban counterparts. Little is known, however, about the quality of care these hospitals provide for emergency operations for which they are most essential.

Methods: We performed a cross-sectional retrospective review of 219,170 urgent or emergency colon resections among Medicare beneficiaries between 2009 and 2012. We compared mortality, serious complications, reoperation, and readmission rates at critical access and non-critical access hospitals using a multivariable logistic regression to adjust for patient factors (age, sex, race, Elixhauser comorbidities,) indication (cancer, diverticulitis, obstruction, inflammatory bowel disease, bleeding), year of operation, and type of operation.

Results: Operative indications were similar at both critical access and non-critical access hospitals with the most common being cancer (38.5% vs 31.1%) followed by diverticulitis (26.9% vs 28.0%). Compared with patients treated at non-critical access hospitals, patients undergoing surgery at critical access hospitals were less likely to have multiple comorbid diseases (% of patients with 2 or more comorbid conditions, 67.5% vs 75.9%; P < 0.01). After accounting for these differences, patients in critical access hospitals had lower risk-adjusted 30-day mortality rates (14.3% vs 16.2%; P = 0.012) and lower rates of serious complications (11.1% vs 27.2%; P < 0.001). However, critical access hospitals had higher rates of reoperation (2.1% vs 1.4%; P = 0.009) and readmissions (22.3% vs 19.4%; P < 0.001).

Conclusions: For emergency colectomy procedures, Medicare beneficiaries in critical access hospitals experienced lower mortality rates but more frequent reoperation and readmission. These findings suggest that critical access hospitals provide safe, essential emergency surgical care, but may need more resources for postoperative care coordination in these high-risk operations.
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http://dx.doi.org/10.1097/SLA.0000000000002216DOI Listing
March 2018