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      Prestige of Training Programs and Experience of Bypass Surgeons As Factors in Adjusted Patient Mortality Rates :

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      Medical Care
      Ovid Technologies (Wolters Kluwer Health)

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          Hospital characteristics and mortality rates.

          The Health Care Financing Administration (HCFA) publishes hospital mortality rates each year. We undertook a study to identify characteristics of hospitals associated with variations in these rates. To do so, we obtained data on 3100 hospitals from the 1986 HCFA mortality study and the American Hospital Association's 1986 annual survey of hospitals. The mortality rates were adjusted for each hospital's case mix and other characteristics of its patients. The mortality rate for all hospitalizations was 116 per 1000 patients. Adjusted mortality rates were significantly higher for for-profit hospitals (121 per 1000) and public hospitals (120 per 1000) than for private not-for-profit hospitals (114 per 1000; P less than 0.0001 for both comparisons). Osteopathic hospitals also had an adjusted mortality rate that was significantly higher than average (129 per 1000; P less than 0.0001). Private teaching hospitals had a significantly lower adjusted mortality rate (108 per 1000) than private nonteaching hospitals (116 per 1000; P less than 0.0001). Adjusted mortality rates were also compared for hospitals in the upper and lower fourths of the sample in terms of certain hospital characteristics. The mortality rates were 112 and 121 per 1000 for the hospitals in the upper and lower fourths, respectively, in terms of the percentage of physicians who were board-certified specialists (P less than 0.0001), 112 and 120 per 1000 for occupancy rate (P less than 0.0001), 113 and 120 per 1000 for payroll expenses per hospital bed (P less than 0.0001), and 113 and 119 per 1000 for the percentage of nurses who were registered (P less than 0.0001).
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            The relation between surgical volume and mortality: an exploration of causal factors and alternative models.

            A previous study of 12 procedures of varying complexity in 1,498 hospitals identified a strong negative curvilinear relationship between the volume of a particular operation and postoperative mortality. The current study uses multiple regression techniques to explore the role of other potentially important variable and alternative interpretations of the volume-mortality relationship. The dependent variable is the difference between the hospital's actual death rate and its expected death rate based upon the riskiness of its case mix. The inclusion of other variables, such as size of hospital, teaching status, geographic location and cost, improves the fit of the regression, but does not diminish the importance of volume. There is no evidence that volume accumulated over 2 years is a better measure than volume in 1 year. Experience and volume of related operations are important in some cases but not others. Several likely alternative explanations for the observed relationship were not supported: larger hospitals and those with more house staff had outcomes that were worse than expected. Large geographic differences in mortality rates remain unexplained. A simultaneous-equation model is used to test whether higher volume leads to better outcomes or better outcomes lead to higher volumes. Both causal paths are supported, but their relative importance varies with the procedure in ways that are consistent with anticipated referral patterns.
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              The decline in coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume.

              To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time. Observation of clinically risk-adjusted operative mortality over time. All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992. All 57,187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals. Actual, expected, and risk-adjusted mortality. Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons ( 150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease. The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).
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                Author and article information

                Journal
                Medical Care
                Medical Care
                Ovid Technologies (Wolters Kluwer Health)
                0025-7079
                1999
                January 1999
                : 37
                : 1
                : 93-103
                Article
                10.1097/00005650-199901000-00013
                2cabd34f-288b-410a-97e5-0eec9c8ae4e7
                © 1999
                History

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