The use of common surgical procedures varies widely across geographical regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain regional variation in surgery rates to only a small degree. Instead, current evidence suggests that surgical variation primarily reflects differences in physician beliefs about the indications for surgery and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help explain the “surgical signatures” of specific procedures, as well as why some consistently vary more than others. Variation in clinical decision making is in turn influenced by broader environmental factors, including technology diffusion, specialist supply and local training paradigms, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions may help mitigate regional variation, but broader dissemination of shared decision making tools will be essential in reducing variation with preference-sensitive conditions.

Background It is generally accepted that hospital volume is associated with mortality in high-risk procedures. However, as surgical safety has improved over the last decade, recent evidence has suggested that the inverse relationship has diminished or been eliminated. Objective To determine whether the relationship between hospital volume and mortality has changed over time. Methods Using national Medicare claims data from 2000 through 2009, we examined mortality among 3,282,127 patients who underwent one of eight gastrointestinal, cardiac, or vascular procedures. Hospitals were stratified into quintiles of operative volume. Using multivariable logistic regression models to adjust for patient characteristics, we examined the relationship between hospital volume and mortality, and assessed for changes over time. We performed sensitivity analyses using hierarchical logistic regression modeling with hospital-level random effects to confirm our results. Results Throughout the ten-year period, a significant inverse relationship was observed in all procedures. In five of the eight procedures studied, the strength of the volume-outcome relationship increased over time. In esophagectomy, for example, the adjusted odds ratio of mortality in very low volume hospitals compared to very high volume hospitals increased from 2.25 [95%CI: 1.57-3.23] in 2000-2001 to 3.68 [95%CI: 2.66-5.11] in 2008-2009. Only pancreatectomy showed a notable decrease in strength of the relationship over time, from 5.83 [95%CI: 3.64-9.36] in 2000-2001, to 3.08 [95%CI: 2.07 - 4.57] in 2008-2009. Conclusion For all procedures examined, higher volume hospitals had significantly lower mortality rates compared to lower volume hospitals. Despite recent improvements in surgical safety, the strong inverse relationship between hospital volume and mortality persists in the modern era.

Importance Previous studies of checklist-based quality improvement interventions have reported mixed results. Objective To evaluate whether implementation of a checklist-based quality improvement intervention, Keystone Surgery, was associated with improved outcomes in patients undergoing general surgery in large statewide population. Design, Setting and Exposure Retrospective longitudinal study examining surgical outcomes in Michigan patients using Michigan Surgical Quality Collaborative clinical registry data from the years 2006–2010 (n=64,891 patients in 29 hospitals). Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period. Main Outcome Measures Risk-adjusted rates of superficial surgical site infection, wound complications, any complication, and 30-day mortality. Results Implementation of Keystone Surgery in participating centers (n=14 hospitals) was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2 vs. 3.2%, p=0.91), wound complications (5.9 vs. 6.5%, p=0.30), any complication (12.4 vs. 13.2%, p=0.26), and 30-day mortality (2.1 vs. 1.9%, p=0.32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in non-participating centers (n=15 hospitals), and sensitivity analysis excluding patients receiving surgery in the first 6- or 12-months after program implementation yielded similar results. Conclusions and Relevance Implementation of a checklist-based quality improvement intervention did not impact rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.

Importance Disparities in operative mortality due to socioeconomic status have been consistently demonstrated, but the mechanisms underlying this disparity are not well understood. Objective To determine whether variations in failure to rescue (FTR) contribute to socioeconomic disparities in mortality following major cancer surgery. Design, Setting and Exposure A retrospective cohort study using the Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. A summary measure of socioeconomic status (SES) was created for each US ZIP code using Census data linked to residence. Multivariable logistic regression was used to examine the influence of SES on rates of FTR, and fixed-effects hierarchical regression was used to evaluate the extent to which disparities could be attributed to differences between hospitals. Participants All patients undergoing esophagectomy, pancreatectomy, partial or total gastrectomy, colectomy, lobectomy or pneumonectomy, and cystectomy for cancer during the years 2003 to 2007 (N=596,222) Main Outcome Measures Operative mortality, post-operative complications, and failure to rescue (case-fatality following one or more major complications). Results Patients in the lowest quintile of SES had mildly increased rates of complications (25.6% in the lowest quintile vs. 23.8% in the highest quintile, p<0.01), a larger increase in mortality (10.2% vs. 7.7%, p<0.001), and the greatest increase in rates of FTR (26.7% vs. 23.2%,p<0.01). Analysis of hospitals revealed a higher FTR rate for all patients (regardless of SES) at hospitals treating the largest proportion of low SES patients. Adjusted odds of FTR according to SES ranged from 1.04 [0.95 – 1.14] for gastrectomy, to 1.45 [1.21 – 1.73] for pancreatectomy. Additional adjustment for hospital effect nearly eliminated the disparity observed in FTR across levels of SES. Conclusions Patients in the lowest quintile of SES have significantly increased rates of FTR. This appears to be, at least in part, a function of the hospital where low SES patients are treated. Future efforts to ameliorate socioeconomic disparities should concentrate on hospital processes and characteristics that contribute to successful rescue.