Faculty Bibliography

OBJECTIVE: This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume. SUMMARY BACKGROUND DATA: The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship. METHODS: A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume. RESULTS: Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10). CONCLUSIONS: For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures

BACKGROUND: Pneumococcal immunization has been shown to be cost effective, is recommended by the Advisory Committee on Immunization Practices, and is covered by Medicare. Despite that, over 50% of the population aged > or =65 is not vaccinated, leading to significant mortality and morbidity. The objective of this study is to evaluate the costs and the cost utility of immunization in nontraditional settings (community clinics set up to provide influenza and pneumococcal vaccinations) as a strategy to increase pneumococcal immunization rates. METHODS: A cost-utility analysis of public immunization clinics in Monroe County, New York, during the fall of 1998. The study included 1207 adults aged > or =65. Costs of operating the clinics and of vaccine administration were measured. The cost of health sequela and estimates of quality-adjusted life years (QALYs) were obtained from prior studies. Sensitivity analyses were performed to test several important assumptions. RESULTS: Unlike immunizations in physician offices, immunizations in nontraditional settings are not cost saving. Estimates of incremental cost-utility ratios ranged from $4215 per QALY to $12,617 per QALY, depending on the underlying assumptions of the model. CONCLUSIONS: Clinics in nontraditional settings offering pneumococcal immunization have cost-utility ratios near and below those of other recommended vaccines. These results suggest that such clinics should be considered a viable strategy for increasing pneumococcal immunization rates