National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 47 Research Studies DisplayedReisz PA, Laviana AA, Zhao Z
Assessing the quality of surgical care for clinically localized prostate cancer: results from the CEASAR study.
Prior studies suggest that nationally endorsed quality measures for prostate cancer care are not linked closely with outcomes. Using a prospective, population based cohort the investigators measured clinically relevant variation in structure, process and outcome measures in men undergoing radical prostatectomy. The authors did not identify and meaningful variation in quality of care across racial groups, age groups and surgeon volume strata, in this cohort, suggesting that men were receiving comparable quality of care across these strata.
AHRQ-funded; HS019356.
Citation: Reisz PA, Laviana AA, Zhao Z .
Assessing the quality of surgical care for clinically localized prostate cancer: results from the CEASAR study.
J Urol 2020 Dec;204(6):1236-41. doi: 10.1097/ju.0000000000001198..
Keywords: Surgery, Cancer: Prostate Cancer, Cancer, Quality of Care, Quality of Life, Patient-Centered Outcomes Research, Comparative Effectiveness, Evidence-Based Practice
Brajcich BC, Bentrem DJ, Yang AD
Short-term risk of performing concurrent procedures with hepatic artery infusion pump placement.
This study’s objective was to characterize the short-term outcomes of concurrent surgery with hepatic artery infusion pump (HAIP) placement using data from the 2005-2017 ACS NSQIP dataset. Findings showed that HAIP placement is not associated with additional morbidity when performed with hepatic and/or colorectal surgery. Decisions regarding HAIP placement should consider the risks of concurrent operations as well as patient- and disease-specific factors.
AHRQ-funded; HS026385.
Citation: Brajcich BC, Bentrem DJ, Yang AD .
Short-term risk of performing concurrent procedures with hepatic artery infusion pump placement.
Ann Surg Oncol 2020 Dec;27(13):5098-106. doi: 10.1245/s10434-020-08938-0..
Keywords: Quality Improvement, Quality of Care, Surgery, Risk, Cancer, Outcomes
Hu QL, Grant MC, Hornor MA
Technical evidence review for emergency major abdominal operation conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.
This technical evidence review focuses on the use of enhanced recovery pathways (ERPs) for emergency major abdominal surgery conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR). This national ERP initiative is funded by AHRQ and implemented in 2017 through a collaboration with American College of Surgeons, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. Five common emergency general surgery (EGS) procedures were focused on: perforated peptic ulcer repair, colectomy, lysis of adhesions, small bowel resection, and exploratory laparotomy. The authors identified seventeen candidate components for emergency major abdominal ERP. The components span the continuum of care from preoperative setting to hospital discharge. For every component they conducted a systematic literature review to find relevant studies. Each component was examined for rationale, evidence, and summary and recommendations. Many were supported by evidence and guidelines specific to their particular operation. Key gaps in literature were highlighted, specifically lack of evidence specific to these operations across many ERP processes.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Grant MC, Hornor MA .
Technical evidence review for emergency major abdominal operation conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.
J Am Coll Surg 2020 Dec;231(6):743-64.e5. doi: 10.1016/j.jamcollsurg.2020.08.772..
Keywords: Evidence-Based Practice, Surgery, Patient Safety, Quality Improvement, Quality of Care, Patient-Centered Outcomes Research
Hu QL, Fischer CP, Wescott AB
Evidence review for the American College of Surgeons Quality Verification part I: building quality and safety resources and infrastructure.
The goal of this review was to synthesize the evidence supporting the first 4 of 12 American College of Surgeons (ACS) Quality Verification Program core principles of building quality and safety resources and infrastructure. Findings showed that, despite heterogeneous study design and lack of randomized controlled trials, the available literature supports the importance of committed top-level hospital leadership, mid-level leadership, and committee dedicated to surgical quality and culture of safety and high reliability. In conclusion, adequate resources and infrastructure integral to the ACS Quality Verification Program are critical to achieving safe and high-quality surgical outcomes.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Fischer CP, Wescott AB .
Evidence review for the American College of Surgeons Quality Verification part I: building quality and safety resources and infrastructure.
J Am Coll Surg 2020 Nov;231(5):557-69.e1. doi: 10.1016/j.jamcollsurg.2020.08.758..
Keywords: Quality Improvement, Quality of Care, Patient Safety, Surgery, Evidence-Based Practice
Merkow RP, Shan Y, Gupta AR
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.
The objective of this study was to define the cost of individual, 30-day postoperative complications using robust cost data from a diverse group of hospitals. Findings showed that the three complications associated with the highest independent adjusted cost per event were prolonged ventilation, unplanned intubation, and renal failure, while the three complications associated with the lowest independent adjusted cost per event were urinary tract infection, superficial surgical site infection and venous thromboembolism. The authors indicated that the actual hospital costs of complications were estimated using cost data from four diverse hospitals, and that these data can be used by hospitals to estimate the financial benefit of reducing surgical complications.
AHRQ-funded; HS024516; HS026385.
Citation: Merkow RP, Shan Y, Gupta AR .
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.
The objective of this study was to define the cost of individual, 30-day postoperative .
Keywords: Surgery, Healthcare Costs, Adverse Events, Quality Improvement, Quality of Care
Schlick CJR, Khorfan R, Odell DD
Adequate lymphadenectomy as a quality measure in esophageal cancer: is there an association with treatment approach?
In this study, the authors’ objectives were to (1) explore trends in adequate lymphadenectomy rates over time; (2) evaluate unadjusted lymphadenectomy yield by treatment characteristics; and (3) identify independent factors associated with adequate lymphadenectomy. The investigators found that despite increases over time, only 50% of patients underwent adequate lymphadenectomy during esophageal cancer resection. They also found that adequate lymphadenectomy was not associated with neoadjuvant therapy.
AHRQ-funded; HS026385.
Citation: Schlick CJR, Khorfan R, Odell DD .
Adequate lymphadenectomy as a quality measure in esophageal cancer: is there an association with treatment approach?
Ann Surg Oncol 2020 Oct;27(11):4443-56. doi: 10.1245/s10434-020-08578-4..
Keywords: Cancer, Surgery, Quality Measures, Quality of Care, Quality Improvement
Leeds IL, Jones C, DiBrito SR
Delay in emergency hernia surgery is associated with worse outcomes.
The purpose of this study was to determine if the variation in timing of urgent surgery impacts surgical outcomes. The National Surgical Quality Improvement Program (NSQIP) database was searched for emergent surgeries in 2011-2016 for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Findings showed that delayed surgery was associated with increased rates of major complications, longer operative times, longer postoperative lengths of stay, increased re-operations, increased readmissions, and increased 30-day mortality. Next-day surgery and surgery delayed more than one day were associated with increased odds of a major complication.
AHRQ-funded; HS024547.
Citation: Leeds IL, Jones C, DiBrito SR .
Delay in emergency hernia surgery is associated with worse outcomes.
Surg Endosc 2020 Oct;34(10):4562-73. doi: 10.1007/s00464-019-07245-4..
Keywords: Surgery, Quality Improvement, Quality of Care, Critical Care, Access to Care, Digestive Disease and Health, Outcomes
Bucher BT, Shi J, Ferraro JP
Portable automated surveillance of surgical site infections using natural language processing: development and validation.
The authors presented the development and validation of a portable natural language processing (NLP) approach for automated surveillance of surgical site infections (SSIs). Patient clinical text notes from EHRs following surgical procedures from two independent healthcare systems were abstracted. The authors found that automated surveillance of SSIs can be achieved using NLP of clinical notes with high sensitivity and specificity.
AHRQ-funded; HS025776.
Citation: Bucher BT, Shi J, Ferraro JP .
Portable automated surveillance of surgical site infections using natural language processing: development and validation.
Ann Surg 2020 Oct;272(4):629-36. doi: 10.1097/sla.0000000000004133..
Keywords: Surgery, Healthcare-Associated Infections (HAIs), Electronic Health Records (EHRs), Health Information Technology (HIT), Quality Improvement, Quality of Care
Mouch CA, Baskin AS, Yearling R CA, Baskin AS, Yearling R
Sleep patterns and quality among inpatients recovering from elective surgery: a mixed-method study.
This study examined sleep quality and barriers to sleep among adult hospital inpatients recovering from elective surgery. A quantitative survey was used followed by a qualitative phone interview with a subsample of participants. Of 113 eligible patients, 102 (90%) completed the survey. Less than half reported sleeping well the night prior to surgery and 93% reported less sleep in the hospital compared to home. A median of 5 (4-7) interruptions were reported each night. Patients with more than three interruptions were likely to report poor sleep compared with those who had three or less. Barriers to sleep included staff interruptions and roommate noise but not pain. Patients interviewed suggested improved timing and knowledge of interruptions or use of noise-reduction aids that would facilitate sleep.
AHRQ-funded; HS026030.
Citation: Mouch CA, Baskin AS, Yearling R CA, Baskin AS, Yearling R .
Sleep patterns and quality among inpatients recovering from elective surgery: a mixed-method study.
J Surg Res 2020 Oct;254:268-74. doi: 10.1016/j.jss.2020.04.032..
Keywords: Sleep Problems, Surgery, Quality Improvement, Quality of Care, Inpatient Care, Hospitals, Patient Experience
Sheetz KH, Ryan A
Accuracy of quality measurement for the hospital acquired conditions reduction program.
Accuracy of quality measurement for the hospital acquired conditions reduction program.
AHRQ-funded; HS026244; HS000053.
Citation: Sheetz KH, Ryan A .
Accuracy of quality measurement for the hospital acquired conditions reduction program.
BMJ Qual Saf 2020 Jul;29(7):605-07. doi: 10.1136/bmjqs-2019-009747..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Quality Measures, Quality Improvement, Quality of Care, Surgery, Infectious Diseases
Kanters AE, Vu JV, Schuman AD AE, Vu JV, Schuman AD
Completeness of operative reports for rectal cancer surgery.
This study examined the completeness of operative reports for rectal cancer surgery and whether they contain the key elements recommended by the National Accreditation Program for Rectal Cancer. Ten hospitals in Michigan submitted rectal cancer operative reports from June-December 2018. These reports were analyzed for completeness and to identify key elements in the synoptic operative template. Out of 110 reports, 31 contained all 24 elements and they all used a synoptic template. Overall, 62 reported used a synoptic template and 48 did not.
AHRQ-funded; HS000053.
Citation: Kanters AE, Vu JV, Schuman AD AE, Vu JV, Schuman AD .
Completeness of operative reports for rectal cancer surgery.
Am J Surg 2020 Jul;220(1):165-69. doi: 10.1016/j.amjsurg.2019.09.036..
Keywords: Cancer: Colorectal Cancer, Cancer, Surgery, Quality Improvement, Quality of Care
Bronsert M, Singh AB, Henderson WG
Identification of postoperative complications using electronic health record data and machine learning.
Investigators developed a machine learning algorithm for identifying patients with one or more complications using data from the electronic health record (EHR). They concluded that using machine learning on EHR postoperative data linked to American College of Surgeons National Surgical Quality Improvement Program outcomes data, a model with 163 predictors from the EHR identified complications well at their institution.
AHRQ-funded; HS026019.
Citation: Bronsert M, Singh AB, Henderson WG .
Identification of postoperative complications using electronic health record data and machine learning.
Am J Surg 2020 Jul;220(1):114-19. doi: 10.1016/j.amjsurg.2019.10.009..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Surgery, Quality Improvement, Quality of Care, Diagnostic Safety and Quality
De la Garza Ramos R, Gelfand Y, Benton JA
Rates, risk factors, and complications of red blood cell transfusion in metastatic spinal tumor surgery: an analysis of a prospective multicenter surgical database.
The goal of this study was to identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery. The multicenter prospective American College of Surgeons National Quality Improvement Program database was used to identify adult patients with disseminated cancer who underwent metastatic spinal tumor surgery from 2012-2016. A patient was included if at least 1 intraoperative/postoperative RBC transfusion was received within the first 72 hours of surgery start time. Out of 1601 patients included, 623 (38.9%) received a RBC transfusion. There was an overall higher complication rate in patients who received a transfusion compared to those who didn’t. These complications included sepsis (3.5% vs. 1.9%), deep vein thrombosis (6.1% vs. 3.3%), and prolonged ventilation (3.9% vs. 1.3%). Future research into complication prevention was recommended.
https://www.pubmed.ncbi.nlm.nih.gov/32298819
Citation: De la Garza Ramos R, Gelfand Y, Benton JA .
Rates, risk factors, and complications of red blood cell transfusion in metastatic spinal tumor surgery: an analysis of a prospective multicenter surgical database.
World Neurosurg 2020 Jul;139:e308-e15. doi: 10.1016/j.wneu.2020.03.202..
Keywords: Quality Improvement, Quality of Care, Surgery, Risk, Cancer
Shetty KD, Robbins M, Aragaki D
The quality of electrodiagnostic tests for carpal tunnel syndrome: Implications for surgery, outcomes, and expenditures.
The quality of electrodiagnostic tests may influence treatment decisions, particularly regarding surgery, affecting health outcomes and health-care expenditures. In this study, the investigators evaluated test quality among 338 adults with workers' compensation claims for carpal tunnel syndrome. The investigators found that in simulations, suboptimal quality tests rendered surgery inappropriate for 99 of 309 patients (+32 percentage points). They also found that test quality was not associated with overall health, actual receipt of surgery, or expenditures.
AHRQ-funded; HS018982.
Citation: Shetty KD, Robbins M, Aragaki D .
The quality of electrodiagnostic tests for carpal tunnel syndrome: Implications for surgery, outcomes, and expenditures.
Muscle Nerve 2020 Jul;62(1):60-69. doi: 10.1002/mus.26874..
Keywords: Diagnostic Safety and Quality, Neurological Disorders, Surgery, Quality Indicators (QIs), Quality Measures, Quality of Care
Khaneki S, Bronsert MR, Henderson WG
Comparison of accuracy of prediction of postoperative mortality and morbidity between a new, parsimonious risk calculator (SURPAS) and the ACS Surgical Risk Calculator.
The purpose of this study was to compare the accuracy of the Surgical Risk Preoperative Assessment System (SURPAS) to that of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). Data from 1006 selected ACS National Surgical Quality Improvement Program (NSQIP) patients with known outcomes were used to calculate predicted risk of postoperative mortality and morbidity. Findings showed that the SURPAS risk predictions were more accurate than the ACS-SRC's for overall morbidity, particularly for high risk patients.
AHRQ-funded; HS024124.
Citation: Khaneki S, Bronsert MR, Henderson WG .
Comparison of accuracy of prediction of postoperative mortality and morbidity between a new, parsimonious risk calculator (SURPAS) and the ACS Surgical Risk Calculator.
Am J Surg 2020 Jun;219(6):1065-72. doi: 10.1016/j.amjsurg.2019.07.036..
Keywords: Surgery, Risk, Adverse Events, Quality Improvement, Quality of Care
Spatz ES, Suter LG, George E
An instrument for assessing the quality of informed consent documents for elective procedures: development and testing.
The objective of this mixed qualitative-quantitative study was to develop a nationally applicable tool for assessing the quality of informed consent documents for elective procedures. The investigators identified key quality elements of an informed consent document and operationalised the highest-priority elements to define a minimum standard for informed consent documents. They assert that this tool is a starting point that can enable hospitals and other providers to evaluate and improve the quality of informed consent.
AHRQ-funded; HS023000.
Citation: Spatz ES, Suter LG, George E .
An instrument for assessing the quality of informed consent documents for elective procedures: development and testing.
BMJ Open 2020 May 19;10(5):e033297. doi: 10.1136/bmjopen-2019-033297..
Keywords: Surgery, Quality Measures, Quality of Care
Spatz ES, Bao H, Herrin J
Quality of informed consent documents among US. hospitals: a cross-sectional study.
The purpose of this study was to determine whether informed consent for surgical procedures performed in US hospitals met a minimum standard of quality. The investigators developed and tested a quality measure of informed consent documents. The investigators concluded that all hospitals performed poorly on a measure of informed consent document quality, though there was some variation across hospitals. They indicated that measuring the quality of hospital's informed consent documents can serve as a first step in driving attention to gaps in quality.
AHRQ-funded; HS023000.
Citation: Spatz ES, Bao H, Herrin J .
Quality of informed consent documents among US. hospitals: a cross-sectional study.
BMJ Open 2020 May 19;10(5):e033299. doi: 10.1136/bmjopen-2019-033299..
Keywords: Hospitals, Surgery, Quality Measures, Quality of Care
Sheetz KH, Chhabra K, Nathan H
The quality of surgical care at hospitals associated with America's highest-rated medical centers.
The objective of this study was to assess whether the quality of surgical care changes as hospitals form networks with established, high-quality medical centers. The investigators concluded that network formation was not associated with a significant improvement in quality or reduction in Medicare expenditures across all procedures studied for hospitals joining the networks of America’s highest rated medical centers.
AHRQ-funded; HS023597.
Citation: Sheetz KH, Chhabra K, Nathan H .
The quality of surgical care at hospitals associated with America's highest-rated medical centers.
Ann Surg 2020 May;271(5):862-67. doi: 10.1097/sla.0000000000003195..
Keywords: Surgery, Hospitals, Quality of Care, Medicare, Health Systems
Smith ME, Nuliyalu U, Dimick JB
Local referral of high-risk pancreatectomy patients to improve surgical outcomes and minimize travel burden.
Referring patients to high-quality hospitals for complex procedures may improve outcomes. This is most feasible within small geographic areas. However, access to specialized surgical procedures may be an implementation barrier. In this study, the investigators sought to determine the availability of high-quality hospitals performing pancreatectomy and the potential benefit and travel burden of referral within small geographic areas.
AHRQ-funded; HS024763.
Citation: Smith ME, Nuliyalu U, Dimick JB .
Local referral of high-risk pancreatectomy patients to improve surgical outcomes and minimize travel burden.
J Gastrointest Surg 2020 Apr;24(4):882-89. doi: 10.1007/s11605-019-04245-6..
Keywords: Surgery, Hospitals, Outcomes, Quality of Care
Alfred M, Catchpole K, Huffer E
Work systems analysis of sterile processing: decontamination.
This study examined the work of sterile processing departments (SPDs) from a systems perspective. This paper reports the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation and identify potential improvement interactions. The analysis was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23,000 units each month. Mixed methods, including 56 hours of observations of work was done, as well as formal and informal interviews with relevant stakeholders and analysis of data collected about the system. The authors identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly with 1% of surgical cases having decontamination problems.
AHRQ-funded; HS025538.
Citation: Alfred M, Catchpole K, Huffer E .
Work systems analysis of sterile processing: decontamination.
BMJ Qual Saf 2020 Apr;29(4):320-28. doi: 10.1136/bmjqs-2019-009422..
Keywords: Patient Safety, Quality Improvement, Quality of Care, Prevention, Surgery, Healthcare-Associated Infections (HAIs)
Tang AB, Childers CP, Dworsky JQ
Surgeon work captured by the National Surgical Quality Improvement Program across specialties.
The National Surgical Quality Improvement Program (NSQIP) database is increasingly used for surgical research. However, it is unclear how well this database represents the breadth of work performed by different specialties. Using the 2017 NSQIP participant use file and the 2017 Medicare Physician/Supplier Procedure Summary file, the investigators evaluated (1) what proportion of surgical work was captured by NSQIP, (2) what procedures and disciplines were undersampled, and (3) the overall concordance between the NSQIP sample and a national sample.
AHRQ-funded; HS000046.
Citation: Tang AB, Childers CP, Dworsky JQ .
Surgeon work captured by the National Surgical Quality Improvement Program across specialties.
Surgery 2020 Mar;167(3):550-55. doi: 10.1016/j.surg.2019.11.013..
Keywords: Surgery, Quality Improvement, Quality of Care, Provider: Physician, Provider, Medicare, Patient-Centered Outcomes Research
Liu JY, Hu QL, Lamaina M
Surgical technical evidence review for acute cholecystectomy conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery.
In this study, the authors identified 13 overall components to consider for a nonelective laparoscopic cholecystectomy for acute cholecystitis enhanced recovery pathways. They indicated that hospitals participating in AHRQ’s Safety Program for Improving Surgical Care and Recovery will be supported in carrying out practices that enhance care for patients and in gathering data to support continuous quality improvement around the enhanced recovery pathways.
AHRQ-funded; 233201500020I.
Citation: Liu JY, Hu QL, Lamaina M .
Surgical technical evidence review for acute cholecystectomy conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery.
J Am Coll Surg 2020 Mar;230(3):354.e1. doi: 10.1016/j.jamcollsurg.2019.11.014..
Keywords: Surgery, Quality Improvement, Quality of Care, Patient Safety, Evidence-Based Practice
Hu QL, Livhits MJ, Ko CY MJ, Ko CY
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
The purpose of this study was to determine whether same-day discharge following thyroid surgery resulted in increased rehospitalization. Data from the American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database was used to identify patients who underwent thyroid resections. Results showed that, in a national cohort of patients undergoing thyroid surgery, same-day discharge was not associated with greater rates of readmission or complications when compared with discharge 1 or 2 days after thyroid surgery.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Livhits MJ, Ko CY MJ, Ko CY .
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
Surgery 2020 Jan;167(1):117-23. doi: 10.1016/j.surg.2019.06.054..
Keywords: Surgery, Ambulatory Care and Surgery, Hospital Readmissions, Hospital Discharge, Adverse Events, Patient-Centered Outcomes Research, Quality Improvement, Quality of Care
Kanters AE, Cleary RK, Obi SH
Uptake of total mesorectal excision and total mesorectal excision grading for rectal cancer: a statewide study.
Investigators sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. They found that the rates of total mesorectal excision performance and grade assignment were widely variable throughout the state of Michigan. Overall, grade assignment remained very low, suggesting an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation.
AHRQ-funded; HS000053.
Citation: Kanters AE, Cleary RK, Obi SH .
Uptake of total mesorectal excision and total mesorectal excision grading for rectal cancer: a statewide study.
Dis Colon Rectum 2020 Jan;63(1):53-59. doi: 10.1097/dcr.0000000000001526..
Keywords: Cancer: Colorectal Cancer, Cancer, Surgery, Quality Improvement, Quality of Care
Sheetz KH, Dimick JB, Nathan H
Centralization of high-risk cancer surgery within existing hospital systems.
Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. In this study, the investigators evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. The investigators concluded that greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes.
AHRQ-funded; HS023597.
Citation: Sheetz KH, Dimick JB, Nathan H .
Centralization of high-risk cancer surgery within existing hospital systems.
J Clin Oncol 2019 Dec 1;37(34):3234-42. doi: 10.1200/jco.18.02035..
Keywords: Surgery, Cancer, Risk, Hospitals, Health Systems, Quality Improvement, Quality Indicators (QIs), Quality of Care, Outcomes