Journal of the American College of Surgeons
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Comparative Study
Risk adjustment in the American College of Surgeons National Surgical Quality Improvement Program: a comparison of logistic versus hierarchical modeling.
Although logistic regression has commonly been used to adjust for risk differences in patient and case mix to permit quality comparisons across hospitals, hierarchical modeling has been advocated as the preferred methodology, because it accounts for clustering of patients within hospitals. It is unclear whether hierarchical models would yield important differences in quality assessments compared with logistic models when applied to American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data. Our objective was to evaluate differences in logistic versus hierarchical modeling for identifying hospitals with outlying outcomes in the ACS-NSQIP. ⋯ When applied to ACS-NSQIP data, logistic and hierarchical models provided nearly identical results with respect to identification of hospitals' observed-to-expected events ratio outliers. As hierarchical models are prone to implementation problems, logistic regression will remain an accurate and efficient method for performing risk adjustment of hospital quality comparisons.
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Payers and professional organizations are expanding accreditation and "centers of excellence" programs in bariatric surgery. Rather than directly measuring outcomes, most programs rely on procedure volume. We sought to determine whether risk-adjusted outcomes or hospital volume were better at predicting future hospital morbidity with bariatric surgery. ⋯ Risk-adjusted morbidity is much better than hospital volume at predicting future performance with bariatric surgery. Rather than focusing on volume, accreditation and centers of excellence programs should focus more on directly measuring outcomes.
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Clinical Trial
Fondaparinux for prevention of venous thromboembolism in high-risk trauma patients: a pilot study.
Venous thromboembolic events (VTE) remain a major cause of morbidity and mortality after trauma. Fondaparinux, a synthetic, nonheparin drug, has shown promise in reducing VTE in orthopaedic patients, but has not previously been studied in trauma patients. The goal of this study was to determine the safety and efficacy of fondaparinux when incorporated into our VTE prevention protocol. We hypothesized that the occult deep vein thrombosis (DVT) rate in high-risk patients receiving fondaparinux would be <5%. ⋯ Fondaparinux appears to offer protection against VTE in high-risk trauma patients. Its once-daily dosing regimen can improve compliance and reduce cost and eliminate risk of heparin-induced thrombocytopenia.
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Like most trauma registries, the National Trauma Data Bank (NTDB) is limited by the problem of missing physiologic data. Multiple imputation (MI) has been proposed to simulate missing Glasgow Coma Scale (GCS) scores, respiratory rate (RR), and systolic blood pressure (SBP). The aim of this study was to develop an MI model for missing physiologic data in the NTDB and to provide guidelines for its implementation. ⋯ This article proposes an MI model for imputing missing physiologic data in the NTDB and provides guidelines to facilitate its use. Implementation of the model should improve the quality of research involving the NTDB. The methodology can also be adapted to other trauma registries.