• Titilope Olanipekun, Devang Sanghavi, Moreno FrancoPabloPDepartment of Critical Care Medicine, Mayo Clinic, Jacksonville, FL., Maisha T Robinson, Mathew Thomas, Sean Kiley, Smit Paghdar, Basar Sareyyupoglu, and Diaz MilianRicardoRDepartment of Critical Care Medicine, Mayo Clinic, Jacksonville, FL.Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL..
• Safety, Quality, Informatics and Leadership Program, Department of Postgraduate Medical Education, Harvard Medical School, Boston, MA.
• Crit. Care Med. 2023 Nov 1; 51 (11): 146114681461-1468.

ObjectivesTo evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation.DesignRetrospective, Observational cohort study.SettingSecondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019.PatientsAdult patients that electively underwent 1 of 19 major procedures.InterventionsNone.Measurements And Main ResultsThe primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 ( n = 2,103,836) and PostM: 2016-2019 ( n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts.ConclusionsWe did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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