The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Source
2.2. Study Population
2.3. Study Outcomes
2.4. Statistical Analysis
3. Results
3.1. National Trends in Procedures and In-Hospital Mortality
3.2. Patient Demographic and Clinical Characteristics
3.3. In-Hospital Outcomes and Disposition Tendencies
3.4. Predictive Model
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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Cohort Characteristics | Hospital Size (n = Number of Open Esophagectomies) | |||
---|---|---|---|---|
Variable | Small (n = 5045) | Medium (n = 12,451) | Large (n = 52,344) | P-Value |
Demographics | ||||
Age | 64.0 (10.8) | 63.7 (10.6) | 63.5 (10.6) | <0.01 * |
Female | 836 (16.6) | 2161 (17.4) | 9406 (18.0) | 0.49 |
Race | 0.62 | |||
White | 3470 (85.5) | 8860 (84.4) | 37,629 (86.7) | |
Black | 156 (3.8) | 498 (4.7) | 1810 (4.2) | |
Hispanic | 253 (6.2) | 669 (6.4) | 2118 (4.9) | |
Asian or Pacific Islander | 85 (2.1) | 236 (2.2) | 712 (1.6) | |
Payer | 0.24 | |||
Medicare | 2131 (42.3) | 5808 (46.7) | 24,252 (46.4) | |
Medicaid | 329 (6.5) | 740 (6.0) | 3154 (6.0) | |
Private | 2307 (45.8) | 5393 (43.4) | 22,851 (43.7) | |
Self-Paying | 163 (3.2) | 157 (1.3) | 766 (1.5) | |
Median Household Income Quartile per Zip Code | 0.43 | |||
1 | 975 (19.7) | 2485 (20.5) | 9977 (19.5) | |
2 | 1322 (26.7) | 2889 (23.9) | 12,517 (24.5) | |
3 | 1409 (28.5) | 3274 (27.0) | 13,426 (26.3) | |
4 | 1241 (25.1) | 3467 (28.6) | 15,194 (29.7) | |
Comorbidities | ||||
Alcohol abuse | 241 (4.8) | 510 (4.1) | 2144 (4.2) | 0.59 |
Deficiency anemias | 963 (19.2) | 2365 (19.2) | 8148 (15.8) | 0.06 |
Chronic blood loss anemias | 98 (2.0) | 268 (2.2) | 890 (1.7) | 0.38 |
Congestive heart failure | 289 (5.8) | 742 (6.0) | 2699 (5.2) | 0.34 |
Chronic pulmonary disease | 1223 (24.4) | 2840 (23.0) | 11,006 (21.3) | 0.12 |
Coagulopathy | 368 (7.3) | 723 (5.9) | 2921 (5.7) | 0.33 |
Depression | 237 (4.7) | 575 (4.6) | 3168 (6.1) | <0.01 * |
Diabetes, uncomplicated | 973 (19.4) | 2037 (16.5) | 8398 (16.3) | 0.08 |
Diabetes with chronic complications | 40 (0.8) | 203 (1.6) | 972 (1.9) | 0.07 |
Hypertension | 2494 (49.7) | 5782 (46.9) | 24,667 (47.8) | 0.37 |
Liver disease | 132 (2.7) | 289 (2.3) | 1208 (2.3) | 0.85 |
Fluid and electrolyte disorders | 1603 (32.0) | 3392 (27.5) | 15,218 (29.5) | 0.24 |
Obesity | 329 (6.6) | 924 (7.5) | 3896 (7.5) | 0.59 |
Peripheral vascular disorders | 262 (5.2) | 423 (3.4) | 1954 (3.8) | 0.1 |
Renal failure | 145 (2.9) | 476 (3.9) | 1776 (3.4) | 0.37 |
Rheumatoid arthritis/Collagen vascular diseases | 64 (1.3) | 116 (0.9) | 668 (1.3) | 0.35 |
Weight loss | 792 (15.8) | 2204 (17.9) | 8444 (16.4) | 0.38 |
Charlson comorbidity index | 4.0 (2.7) | 4.3 (2.8) | 4.3 (2.8) | <0.01 * |
Prior radiation | 632 (12.5) | 1182 (9.5) | 5105 (9.8) | 0.20 |
Atrial fibrillation | 1115 (22.1) | 2748 (22.1) | 11,175 (21.4) | 0.71 |
Smoking | 1589 (31.5) | 3989 (32.0) | 15,695 (30.0) | 0.23 |
COPD | 96 (1.9) | 275 (2.2) | 850 (1.6) | 0.16 |
Prior MI | 745 (14.8) | 2040 (16.4) | 7186 (13.7) | 0.01 * |
Prior TIA/Stroke | 715 (14.2) | 1732 (13.9) | 7875 (15.1) | 0.38 |
Admission Characteristics | ||||
Admission on weekend | 82 (1.7) | 453 (3.6) | 1594 (3.0) | 0.26 |
Elective admission | 4484 (89.2) | 10,902 (87.7) | 47,241 (90.4) | 0.04 * |
Hospital Factors | ||||
Control/ownership of hospital | <0.01 * | |||
Government, nonfederal | 254 (5.0) | 199 (1.6) | 2900 (5.5) | |
Private, not-for-profit | 1067 (21.2) | 3064 (24.6) | 14,538 (27.8) | |
Private, investor-owned | 328 (6.5) | 680 (5.5) | 2508 (3.6) | |
Location/teaching status of hospital | <0.01 * | |||
Rural | 38 (0.7) | 79 (0.6) | 2052 (3.9) | |
Urban nonteaching | 481 (9.5) | 2528 (20.3) | 9699 (18.5) | |
Urban teaching | 4526 (89.7) | 9843 (79.1) | 40,593 (77.6) | |
Region of hospital | 0.01 * | |||
Northeast | 740 (14.7) | 2083 (16.7) | 13,162 (25.2) | |
Midwest | 1420 (28.1) | 2634 (21.2) | 12,808 (24.5) | |
South | 1879 (37.2) | 4331 (34.8) | 17,189 (32.8) | |
West | 1007 (20.0) | 3402 (27.3) | 9184 (17.6) |
Patient Outcomes | Size of Hospital (n = Number of Open Esophagectomies) | |||
---|---|---|---|---|
Variable | Small (n = 5045) | Medium (n = 12,451) | Large (n = 52,344) | P-Value |
In-Hospital Outcomes | ||||
Acute myocardial infarction | 90 (1.8) | 217 (1.7) | 731 (1.4) | 0.32 |
Acute kidney injury | 415 (8.2) | 903 (7.3) | 4125 (7.9) | 0.54 |
Cardiac arrest | 46 (0.9) | 198 (1.6) | 577 (1.1) | 0.09 |
Major bleed | 226 (4.5) | 626 (5.0) | 2754 (5.3) | 0.53 |
Vascular complications | 210 (4.2) | 552 (4.4) | 2254 (4.3) | 0.94 |
Stroke | 27 (0.5) | 111 (0.9) | 305 (0.6) | 0.19 |
Aspiration | 280 (5.5) | 850 (6.8) | 2919 (5.6) | 0.17 |
Pulmonary insufficiency | 657 (13.0) | 1444 (11.6) | 6902 (13.2) | 0.33 |
Post-operative cardiac complications | 412 (8.2) | 1071 (8.6) | 4192 (8.0) | 0.66 |
Pneumonia | 795 (15.8) | 1757 (14.1) | 7123 (13.6) | 0.18 |
Reintubation | 738 (14.6) | 1585 (12.7) | 6259 (12.0) | 0.10 |
Reoperation for bleeding | 0 (0.0) | 5 (0.04) | 21 (0.04) | 0.82 |
Death | 260 (5.2) | 852 (6.9) | 2738 (5.2) | 0.01 * |
LOS (days) | 15.9 (12.4) | 16.8 (14.4) | 16.5 (15.2) | <0.01 * |
Cost (USD, inflation adjusted) | 73, 413 (67,706) | 78,635 (81,076) | 74,752 (74,304) | <0.01 * |
Disposition (not including death) | 0.48 | |||
Routine | 1904 (37.7) | 4683 (37.7) | 19,129 (36.6) | |
Transfer to short-term hospital | 99 (2.0) | 143 (1.2) | 486 (0.9) | |
Transfer to SNF, ICF, rehab | 838 (16.6) | 1904 (15.3) | 8146 (15.6) | |
Home health care | 1944 (38.5) | 4815 (38.8) | 21,747 (41.6) |
Variable | Odds Ratio | 95% Confidence Interval | P-Value | |
---|---|---|---|---|
Small Hospital Size | (ref) | |||
Medium Hospital Size | 1.48 | 1.04 | 2.10 | 0.03 * |
Large Hospital Size | 1.11 | 0.81 | 1.51 | 0.55 |
Coagulopathy | 2.99 | 2.42 | 3.69 | <0.01 * |
Liver Disease | 2.37 | 1.68 | 3.33 | <0.01 * |
Fluid and Electrolyte Disorders | 2.19 | 1.86 | 2.59 | <0.01 * |
Congestive Heart Failure | 1.85 | 1.44 | 2.39 | <0.01 * |
Nonelective Status | 1.83 | 1.47 | 2.28 | <0.01 * |
Weight Loss | 1.46 | 1.22 | 1.76 | <0.01 * |
Renal Failure | 1.45 | 1.07 | 1.97 | 0.02 * |
Age | 1.04 | 1.03 | 1.05 | <0.01 * |
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Hirji, S.A.; Shah, R.M.; Fields, A.; Orhurhu, V.; Bhulani, N.; White, A.; Mody, G.N.; Swanson, S.J. The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy. Medicina 2019, 55, 669. https://doi.org/10.3390/medicina55100669
Hirji SA, Shah RM, Fields A, Orhurhu V, Bhulani N, White A, Mody GN, Swanson SJ. The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy. Medicina. 2019; 55(10):669. https://doi.org/10.3390/medicina55100669
Chicago/Turabian StyleHirji, Sameer A., Rohan M. Shah, Adam Fields, Vwaire Orhurhu, Nizar Bhulani, Abby White, Gita N. Mody, and Scott J. Swanson. 2019. "The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy" Medicina 55, no. 10: 669. https://doi.org/10.3390/medicina55100669